
Class WU3S* 

Book tyfhST 

Copyright^ _ 

COPYRIGHT DEPOSIT. 



SURGICAL DIFFERENTIALS 



BY 



J. W. DRAPER MAURY, M.D., 

ROCKEFELLER INSTITUTE RESEARCH FELLOW IN THE LABORATORY OF 
EXPERIMENTAL SURGERY 

COLU M B I A U X I V E R S I T V 

NEW YORK CITY. 



ILLUSTRATED. 



PUBLISHED BY 

James T. Dougherty, 

409 & 411 West 59th Street, 
NEW YORK CITY. 

1904 



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LIBf»»ffV nt CONGRESS 
Two Cooles flece'ved 

SEP 29 1904 

(£%.//. t*o4- 

CLASS CL tfVo. No. 



5PY B 



COPYRIGHTED, 1904, 
BY 

J. W. DRAPER MAURY, M. D, 



THEO. GAUS' SONS, Pbintebs,. 

42 Franklin Street, 

NEW YORK. 



TO MY MOTHER. 



PREFACE. 

"Diagnosis" has for some time been accepted as meaning 
"Differential Diagnosis." This term is too long for conveni- 
ent nse and of the two words, clearness seems to demand that 
"diagnosis" be dropped. This is offered as an explanation of 
the title of this book. 

The subject matter has been compiled with but a single 
purpose. This is to present to students intending to enter the 
competitive examinations of the New York Hospitals, a well- 
tried scheme and its mode of application. It is not the actual 
learning of surgical facts but their selection and grouping 
which is most difficult to the student. 

In the opinion of over one hundred graduates who during 
the past six years secured hospital positions, the ability to apply 
this scheme was the primary cause of their success. These 
■ pages represent simply an effort to present as tersely as possible 
the system which has proved so highly efficacious. It will 
therefore be seen that no attempt to make a text-book or 
book of reference has been thought of. 

Ability to sketch rough outlines in place of giving 
long word answers has always been very helpful in secur- 
ing hospital positions. In recognition of this, forty graphic 
illustrations have been introduced. They were made by Dr. 
Chas. K. Stillman, a successful graduate of last year. Hav- 
ing been made by a student they can be duplicated by a stu- 
dent, for they have been drawn with studied simplicity and it 
is believed, with accuracy. Except in three or four instances 
they are entirely original; — I cannot too cordially thank Dr. 
Stillman for his care, or endorse his work too highly. 



Copies of some recent hospital examination papers have 
been added, in the interest of students at Universities outside 
of New York City. 

The Differentials have been made with care and by pains- 
taking- reference to leading text-books. It is feared, neverthe- 
less, that many errors may be found. These Differentials have 
been chosen with the intention of indicating the general broad 
trend of to-day's hospital questions. The time for memorizing 
special material for each examiner is happily past and with it 
the value of the obnoxious "quiz compend.'* Examiners no 
longer ask for narrow isolated facts but require the broad prac- 
tical Differential. 

Dr. Jos. A. Blake, Dr. Geo. E. Brewer, Dr. R. H. M. 
Dawbarn, Dr. John Rogers and Dr. L. A. Stimson may 
recognize in the text some of their own familiar aphorisms. 
The author wishes to acknowledge the debt which he owes 
these Teachers of Surgery. 

J. W. Draper Maury. 
September 1st, 1904. 



CHAPTER I. 
SCHEME. 

A clear and uniform recitation scheme is essential to every 
student of medicine. This is particularly true of those who 
enter competitive hospital examinations. 

For more general surgical diseases the same scheme may 
be applied which is universally used in the practice of medicine. 

., ^ \ Simple — Such as is given in a modern gen- 

1 — Definition j . * , ,. & .. & 

I eral dictionary. 

f Predisposing — Age, sex, race, color, 

„ p j occupation, social status, climate. 

tiolo y i j p-erms or 

Exciting — Iraumadueto - **. -, 

., -r, i Gross. 

3 — Pathology < ■»»• . 
/ Minute. 

f Subjective or / s s , _ chenie T 
1 General Symptoms \ bee ^ ub " scheme l 
4 o 1 Inspection 

4 SYMPTOMATOLOGY -^ A , • ■ t» 1 *« 

Objective or I Palpation 
| Local Symptoms { Percussion 

J Auscultation 

5 — Differentials — (See Sub-scheme II) 

,. n o i Immediate, mediate and 

b —Complications and Sequelae ■{ ' 

/ remote 

7- Prognosis j ifcdtate** I As t0 life a f ndvet " m ot " function 
/ Remote of ,n J ured P art 



Nurse 
Medical r 



| Medical ,- Feed 

) Stimulate 



• i ) Pallative 
Surgical r -n -,. , 
& Radical 



SCHEME. 



SUB-SCHEME I. 



Many surgical lesions, however, require further detail 
than this familiar scheme affords. 

In giving subjective symptoms, for example, it has been 
found convenient to follow the course of a particle of food 
through the body. All the patient complains of in the usual 
surgical lesions is pain or disability. One or both of these 
symptoms may occur in the 



1, 


Mouth 


8, 


Heart 


2, 


Pharynx 


9, 


Lungs 


3, 


Esophagus 


10, 


Brain 


4, 


Stomach 


11, 


Special senses 


-5. 


Small and great gut 


12, 


Peripheral nerves 


6, 


Liver (Jaundice) or other 


13, 


Kidneys and G. U. 




glands 


14, 


Extremities 


?, 


Here the food enters the 
blood from which indi- 
rectly is derived the 
T. P. R. 







SUB-SCHEME II. 

■Historic Differentials, 
#, History of Tumor, Injury, Disease or Malformation. 



Note. 



-T. I. D. as used in prescription writing, convenient way 
to remember this. 



b, History of previous Injury, Disease or Operation. . 

c, Age, Sex, Race, Occuption, Social State, Climate. 



2 — Subjective Differentials. 
<?, Pain — Local and referred. 



b, Disability 

c, Vomiting 
J, Bladder 

and Rectum 



e, Jaundice 
/, T. P. R. 



j Important always to give the actual 
( figures. Never say elevated or de- 
pressed. 

120 is the danger line of the pulse. 
Pulse has six characteristics : Force, 
Frequency, Rhythm, Length, Foll- 
P— { ness, Compressibility* The first three 
are determined by the heart, the 
last three by the condition of the 
vessel wall. 



SCHEME. 



f Central (vertigo, delirium, con- 

AT , J sciousness, convulsions) 

°\ Nervous symptoms - { -n ■ , , / ' .-. • ' • ^ 

*' r Peripheral (paresthesiae, special 

sense) 



h, Urinary symptoms. 



3 — General Physical 
Differentials 



Inspection 
Facies 
Nutrition 
Glands 

Superficial and 
Deep Reflexes 



r Inspection 
Palpation / Pressure 
4 — Local Physical J Percussion [ pain 
Differentials ' Auscultation 

I Mensuration / Serous Sangui- 

[ Exploratory Puncture f nous Purulent 



5 — Laboratory Differentials. 

A, Sputum 

B, Stomach 

t FreeH. CI. (N. = T \f ) 

a, Chemical of contents ■! Combined H. CI. 

( Carbon Compound Acids 

b, Physical of contents — Color, sediment, odor, etc. 

( Boas-Oppler 
r, Microscopic of Contents < Sarcinae 

( Atypical Cells 



<aT, Motor Power of Stomach •< 



X-ray (with Bismuth). 
K. I. in capsules 
Asparagin 

Measured quantity of 
liquid 



C, Blood 

a, Leucocyte Count, Differential Count 

Small lymphocites, 20-30 % 
Large ' ' 4-8 % 

(Normal) -{ Polymorphonuclear neutrophiles, 

62-70 # 

^ Eosinophiles, ^-4^ 



ID SCHEME. 

/;, Hemoglobin per cent 

c, Color Index (Hemoglobin per cent divided by per 
cent of red cells. Normally one.) 

J, Parasites (Malaria, Spirillum, Bacteria, etc.) 
c\ Injection into animals 
/, Widal and other tests 

D, Urine in addition to usual tests 

Indican (Intestinal putrefaction) 
Cryo^feopy (In renal involvement) 

E, Feces: Undigested Food, Blood, Ova, Parasites, Bac- 

teria. 

F, Tissue Section and Staining Reactions 

/- T7 • r -n i. n • i ( Specific Gravity. 

G, Examination of Punct. rluid, ] *K. 

Exudate, Transudate or Pus ) p 

•6 — Drug Differenhals. 

Effect of K. I. Hg., Quinine, etc. 

7 — Mechanical Differentials. 

Effect of Rest, Extension, X-ray, Hydrotherapy, etc. 

-8 — Exploratory Incision. 



SUB-SCHEME III. 

To answer the frequently asked question "Causes of." 
For example: Causes of hemorrhage; of dyspnea; of vomit- 
ing, etc. All such questions are answered by reference to the 
first portion of Sub -Scheme II, viz. 

(T.I.D.) TUMOR. INJURY, DISEASE OR MALFORMATION. 

If the question is so framed as to require the causes of a 
lesion of one of the hollow viscera T. I. D. M. should be applied, 
— within the lumen : to the wall of the viscus, and to the region 
about it. It will thus be seen that by applying this simple 
scheme to such question as the causes of intestinal obstruction, 
no less than twelve points are immediately suggested by the 
scheme for discussion. 



SCHEME 11 

Such a system of schemes would be too long and cumber- 
some for practical use unless abbreviated and adjusted to each 
subject, and in recitation work it is not intended that the nega- 
tive, but only the positive and most important factors be dwelt 
upon. The advantage of knowing a system such as has been 
given is that if called upon to talk on any given subject or to 
write about it, the work can be done speedily, fully and without 
hesitation. In the pages which follow, an attempt will be made 
to pursue in general the outlines suggested, but it will be read- 
ily seen that they cannot advantageously be followed in full. 
It may be well before going on to a general consideration of 
certain surgical questions, to illustrate in some detail the mode 
of application of these schemes. 

Apply, for example, the general scheme to such a disease 
as erysipelas. This is intended to be used if a general descrip- 
tion of erysipelas be asked for. If, however, the subjective or 
general. symptoms of the disease be desired, apply "Sub-Scheme 
I." If the differential diagnosis, — and it may here be said that 
in any case, whenever diagnosis is asked for, it is understood 
to signify differential diagnosis. — apply "Sub-Scheme II." 

As the application of this scheme is possibly a little more 
complicated than that of the preceding, it may not be amiss 
to follow it out in detail. 

As suggested, the phrase "T. I. D." with an M added to it 
is the first thing to think of for differential diagnosis. 

Tumor? Negative. Injury? The patient may or may 
not be cognizant of having been injured. Disease? Onset 
sudden and severe. Malformation? Negative. 

History of previous injury? 'Slay or may not be negative. 
Of previous disease? Often affirmative. 

History of operation? Positive or negative. 

Age? More common in early adult life. 

Sex? Somewhat more common in the male. 

Occupation? More common in those exposed to trauma- 
tism. 

Social State? Negative. 

Pain? Usually not marked. "Stiff." 

Disability? Present. 

Vomiting? Often a prominent symptom. 



12 SCHEME. 

Bowels? Irregular. 

Jaundice? Absent. 

T. P. R. ? 105, 120, 24. 

Nervous Symptoms? Early delirium. 

Glands? Typical involvement of glands in the neighbor- 
hood, specially true of facial infection. 

Reflexes? Negative. 

Inspection? Swelling; peculiar color. 

Palpation? Typical harsh feel. 

Sputum ? Negative. 

Stomach? Negative. 

Blood? Leucocyte count roughly parallel with tempera- 
ture chart. (A^on-Limbeck). 

Differential Count? Marked increase in polymorpho- 
nuclear cells. 

Hemoglobin per cent? Negative. 

Color Index? Less than one. 

Parasites? Bacteria not in sufficient numbers to be read- 
ily seen. 

Injection? Toxic to animals. 

L T rine? Free amount of albumin and finely granular casts, 
if far enough progressed. 

Indican? Negative. 

Cryoscopy? Negative, except in presence of renal disease. 

Feces ? Negative. 

Tissue Section? Bacteria seen crowding the lymphatic 
spaces. 

Such a scheme as this is of necessity cumbersome, but it 
affords the only known means of covering a given subject 
rapidly without omitting any important details. 

It will clearly be seen that the points established here will 
serve to differentiate this disease as clearly as it may be from 
any disorder with which one might confound it. 

Throughout these notes, the terms "Proximal" and 
"Distal" will be used, the heart being understood to be the 
center. 



SCHEME 13 

In less detail apply this scheme for differentials to: — 

Non-impacted Fracture of Dislocation of Femur. 

Neck of Femur. (Dorsal) 

TUMOR. 

Moderate fullness in Scarpa's If thin, marked, postero, ex- 

triangle, ternal. 

INJURY. 
Moderate violence. Great violence. 

PREVIOUS INJURY. 
Not infrequent. Absent. 

PREVIOUS DISEASE. 

Some form of rarifying osti- Absent, 

tis, not uncommon. 

AGE. 

Past adult life. Adult life. 

SEX. 
Female. Male. 

OCCUPATION. 
Sedentary Hard labor. 

PAIN. 
Great, but not constant. Excruciating, constant. 

DISABILITY. 

Typically complete unless Complete, 

impacted. 

INSPECTION. 

Characteristic attitude, ex- Flexion, internal rotation, 

tension and external rota- adduction, 

tion. Postero-external swelling. 

Moderate swelling in Scarpa's 
. triangle. 

PALPATION. 

Pain increased on crowding Pain decreased on crowding 
extremity upward. extremity upward. In- 
Decreased by traction. Mod- creased by traction. May 
erate tenderness in Scarpa's ^ e Crepitus. 
triangle. May be Crepitus. 



14 SCHEME. 

MENSURATION. 
Fracture, Nelaton's Line. Dislocation. 

Tip of great tuberosity, prox- Relation to line, not constant, 

imal to, instead of upon it. 

BRYANT'S TRIANGLE. 

Negative or minus. May be approximately nor- 

mal. Variable. 

TAPE MEASURE. 

Shortening from ^ to 3 in- May be shortening or length- 

ches A. S. S. to internal ening. 

maleolus. 

LABORATORY FINDINGS. 
Obviously negative in this class of cases. 

Subjective symptoms are frequently asked for. It must 
be understood in the use of the schemes that that one is in- 
tended to be utilized, which is obviously most applicable to 
the disease or injury under consideration. For example, as 
has been said before, the general scheme is indicated chiefly 
in the wider or more general surgical diseases, although there 
is hardly any form of lesion to which it may not be applied. 
In the case of more localized injuries, as for example fractures, 
the scheme must necessarily be a narrow and exact one. This 
is further considered in the Chapter on Fractures. 

The giving of subjective symptoms is very much facilitated 
by remembering that practically all surgical lesions present 
but two subjective symptoms — Pain and Disability. 

Should a disease presenting such multifarious symptoms 
as, for example, colelithiasis, be asked for, the subjective symp- 
toms are easily given by Sub^Scheme I. Disability can be 
understood to include a broad variety of conditions, — almost 
anything deviating from the normal. It may be local or gen- 
eral, and of any degree. In this disease, the patient will not 
have observed anything abnormal in Mouth, Pharynx or 
Esophagus. 

Stomach ? This is typically the seat of pain and disability 
so great that eminent authorities have found it difficult to dif- 
ferentiate between colelithiasis and carcinoma of the pylorus. 



SCHEME. 15. 

Small and great gut? There is no pain save that attending^ 
habitual constipation. The disability results in clay colored 
stools. 

Liver or other glands? Jaundice depending on the posi- 
tion of the stomach and other factors. Often pain at Robson's. 
point. 

Lungs? Foul breath. 

Brain? Headache and increasing dyscerebration. 

Special Senses? Yellow conjunctivae. 

Peripheral Nerves? Paresthesiae frequent. 

Kidneys and G. U.? Bile stained urine. 

Extremities? Progressive disability. 



No claim for special excellence or for any originality is; 
made for these schemes. They have been printed in their 
present form on the conviction that what has worked well for 
one series of men will work well for another. Individuals will 
probably be able to modify them to suit their needs and fancies, 
but adherence to some such general system will win in the 
future as it has in the past, the much coveted Appointments, 
in the New York Hospitals. 



CHAPTER II. 

INFLAMMATION. 

In the erection of any building, a scaffolding is the first 
consideration. Even if the work be simply the repair of an 
existing edifice, this scaffolding must begin at the ground and 
reach to the break. It often costs more than the repairs. 

Such a scaffolding is used in nature. A clear grasp of this 
simple proposition makes the subject of inflammation, gener- 
ally considered a great bugbear difficult to understand and un- 
interesting, a very simple matter. 

The subject of tissue repair is by no means intricate. The 
process naturally depends, as in the case of a building, on the 
degree of repairing which is to be done. The red cells and 
the plasma are the bricks and mortar ; the phagocytes and 
nature's other agents are the laborers. 

If the injury to the parts be not so severe as to have act- 
ually destroyed cellular life, the scaffold erection naturally 
does not take place. Consider the familiar case of a weal on 
the back of a horse. It rises soon after the horse is struck 
with the lash. What happens? Something very easy to 
understand. There is a disturbance of the vaso-motor nerves. 
The small vessels along the line of the traumatism immedi- 
ately dilate ; as a natural consequence, the current slows. The 
leucocytes, presenting a greater degree of resistence from their 
larger size and coarser texture, naturally lag behind and are 
arranged around the outside of the stream against the vessel 
wall. Following their instinct, they immediately begin to emi- 
grate through the chinks of the endothelial lining. 

Fig. 1. 




Figure showing emigration of leucocytes. 



SIMPLE EXUDATIVE INFLAMMATION. 17 

Coincidental with this the fluid part of the blood leaks out 
into the intercellular spaces. If the blow has been a hard one, 
a certain number of red cells will pass out in a manner some- 
what similar to that described for the white cells. This pro- 
cess is called diapedesis. In most cases of moderate injury, 
probably a few of these erythrocytes escape from the vessels. 

This process, in the case of the horse under consideration, 
continues at so rapid a rate, that a local swelling is produced, 
This is because the exudate, as the materials which pass out 
are called, cannot be diffused into the neighboring tissues as 
rapidly as they are extruded. It requires only common sense 
to see that as this process continues, the characteristic weal 
will form. After the recovery of the vaso-motor nerves, a 
balance is gradually established between the rate of exudation, 
— the vessels gradually assuming their normal tone, — and the 
absorption of the exudate into neighboring uninjured vessels. 
The establishment of this balance marks a cessation in the 
growth of the weal and immediately thereafter, the ridge be- 
gins to be absorbed. Any one, who has had anything to do 
with horses, knows that this may take twelve, twenty-four or 
even more hours before its completion. 

In this case there has been no need of a scaffolding, for the 
only moderately injured tissues have returned entirely to nor- 
mal. The process which has been here portrayed has been 
named Simple Exudative Inflammation. 

This simple exudative inflammation will be found to be 
the direct cause of the symptoms of many of the minor sick- 
nesses, both medical and surgical. Whether it attacks the 
mucous membranes, as is evidenced by a cold in the head, an 
inflammation of the uterus or of the gut ; whether it occurs 
in connective tissue, in the muscles, or in any of the hard or 
soft parts of the body, the process is always the same, a sim- 
ple affair easy to understand. 

However, the organism is not always so fortunate as to 
have its cells live after the primary injury, and it may there- 
fore become necessary for it to replace those which have been 
lost. It is not meant by this that the organism is always able 
to replace the special cells which were lost if they belong to a 
very specialized type, but connective tissue cells, at any rate, 



18 (GRANULAR CHANGE. 

are created to repair the loss of continuity and prevent the 
danger of infection. 

Now suppose a case in which the injury has been sufficient- 
ly severe and of such nature as to have admitted pus produc- 
ing germs to the part. It is wise to remember that almost any 
germs with the exception of a few such as the tetanus bacillus 
and the diphtheria bacterium, which remain localized, can 
all produce pus. Now, if some of these germs, either in pure 
culture or in mixed, are introduced into this wound of graver 
character which we are considering, the tissues have, in addi- 
tion to the primary injury, to fight against the poisonous 
toxins which are created by the germs. They are simply the 
products of the life of these organisms, but they produce when 
in small quantity what is knOwn as Cloudy Swelling, — a con- 
dition in which the protoplasm of the cell is seen under the 
microscope to be granular and the nucleus to have become in- 
distinct — and when in large quantities, early death of the cell. 

Undoubtedly, in a great many cases which grossly appear 
to be simple exudative inflammation, as in the case of a weal 
before referred to, there are a moderate number of cells w T hich 
undergo this cloudy swelling. It is to be understood that 
this condition gives rise to no marked symptom by which it 
may be recognized clinically. The cells, w r hich have under- 
gone this granular change, either return to their normal con- 
dition in the course of a few days, or else they die. If they die, 
they disintegrate, and the particles are removed by the phago- 
cytes and t by the circulating plasma. This process takes place 
slowly and gives no gross external evidence. 

Suppose the double trauma of injury and poison to have 
been so great that the cells, not only underwent granular 
change, but actually died. What then takes place? Death 
occurs not only in the cells of the inflamed connective tissue, 
but also in any parenchymatous cells which may be in the 
neighborhood. The entire mass becomes 'saturated with the 
body fluids. It is "Walkd Off" by nature from the living 
parts and an effort is made by the organism to extrude it. 

This is the type of the process which takes place when a 
stitch abscess forms, or an ordinary boil develops. The so- 
called core of the boil is the mass of dead lymphatics and 



PRODUCTIVE INFLAMMATION. 19 

other vessels, nerves, muscular and other tissues, together with 
the blood elements which extrude into the tissues, as before 
described, immediately after the beginning of the injury. In 
the case of the boil, the traumatism is either absent or in- 
significant as compared with the infection. This core, so 
familiar to all, is removed, and the parts are then in position 
to begin to heal. Now it is that the scaffolding is erected. 
It consists of a reticulum or net work of fibrin, whica fills the 
whole part as though a spider had woven a web in every di- 
rection within the cavity. Leucocytes and erythrocytes swarm 
along the strands of this network and become entangled in its 
meshes. The process of creation of what is known as scar 
tissue is technically called Productive Inflammation. It will 
be noted that whereas the changes referred to in exudative 
inflammation have affected the vessels only, those in produc- 
tive inflammation have to do particularly with the changes 
in the cells of the affected part. 

Productive Inflammation may or may not be accompanied 
by an appreciable degree of exudative inflammation. In any 
reconstructive process, there is probably always a certain 
amount of exudation taking place. Nevertheless, it is cer- 
tain that there are types of productive inflammation which are 
to be seen at certain periods in the healing of granulating 
wounds in which the fluid is taken up by the parts just as rap- 
idly as it is extruded. This may be called dry productive in- 
flammation, as contrasted to the combined or wet form. The 
typical example, however, of dry productive inflammation is 
to be seen in the so-called sclerotic changes of the arteries and 
the cirrhoses of the liver, kidneys and other organs. 

The boil under consideration has reached the condition 
in which the scaffolding has been erected and the laborers 
with their bricks and mortar are aloft. It is obviously not pos- 
sible for them to recreate the intricate arrangement of the 
tissues as it existed prior to the toxemic injury. What they 
proceed to do, therefore, is to make granulation tissue, which 
in course of time turns white, and is known as a Scar. 

How is this done? A great deal is heard now-a-days about 
abscesses being "walled off." This term is used every day 



20 CHEMOTAXIS. 

in speaking of appendicitis. What is the wall and where does 
it come from? 

]>y a process which has been called Chemotaxis, white 
cells from far and near have been called into the neighbor- 
hood of the injury. They arrange themselves in the form of 
a hollow sphere about the dead part and after assuming the 
function of thus protecting the general body from invasion, 
they are called instead of leucocytes, phagocytes from the 
Greek phagein — to eat. From having been simple white cells, 
they become, by a process of conscription, or chemotaxis, the 
eating or defending cells. 

Nowhere can the process about to be described be seen 
more beautifully than in one of the small tubercles so frequent- 
ly observed in the muscular tissue of the diaphragm. These 
tubercles may for the purposes of description be regarded as 
miniature boils, and as the whole tubercle may be seen under 
one field of the microscope, which is not the case with a boil, 
the process of "walling off" may be conveniently and accur- 
ately studied in it. What is true of the wee tubercle is equally 
true of the large boil, and what is true of the boil is true of 
the appendicular or pyemic abscess containing a pint to a 
quart of pus. The point is to understand that this process is 
the same for all like conditions irrespective of their size or 
position. So in the great abscess, the tubercle or the boil, this 
hollow spherical layer of protecting white cells masses itself 
between the well tissues on the one hand and the dead on the 
other, — between the sterile body on the one side and the in- 
fected wound on the other. Between the phagocytes there is 
some fibrin. This is what is meant by "walling off." There 
are other elements in the "wall" as will be seen later, but this 
"Round Cell Zone" is all-important. 

The next element to consider in the process of dry produc- 
tive inflammatory regeneration are the so-called Fibroblasts. 
Whether they are derived from pre-existing connective cells, 
or whether they spring from certain of the white cells, is not 
definitely known, but the practical point is that coincidental 
with the establishment of the -zone of white cells, already de- 
scribed, there is laid down between the dead part and the outer 
wall of leucocytes, a secondary wall of these fibroblasts. These 



HOW TO KNOW A FIBROBLAST. 21 

are to strengthen the "wall." A convenient way to remember 
about these fibroblasts is to ask the question : 

How does a fibroblast differ from a woman? The answer 
is that the fibroblast is fat when it's young and thin when it's 
old, whereas a woman is thin when she's young, and fat when 
she's old. 

This is a homely and perhaps ungallant means of stating 
the life history of the fibroblast. By mutual pressure, and by 
pressure derived from the outside shell of phagocytes ; called 
"Round Cell Inflammatory Zone," — the fibroblasts assume first 
a hexagonal form and are finally pressed out into the familiar 
ribbons characteristic of fibrous tissue. A good illustration 
to show how this process begins may be seen in the Giant's 
Causeway at the North of Ireland, where by mutual pressure 
columns many feet in length have been formed, each and every 
one being hexagonal. Drops of mercury, when allowed to 
press upon each other, will also become hexagonal before they 
are confluent. 

As the young fat fibroblast gradually elongates, its nucleus 
becomes more and more indistinct until it is finally lost. Be- 
fore this takes place, however, the cell accomplishes the pur- 
pose for which it was in part designed, viz. — the deposition 
of intercellular material. This aids largely in the formation 
of the fibrous tissue. 

Starting with a comparatively small number of these 
young fibroblasts, it is necessary that they should be multiplied 
as rapidly as possible. This is accomplished in part by emigra- 
tion, just as among people in a new territory; in part by re- 
production. This takes place by the process formerly known 
as karyokinesis, but now commonly called mytosis. The great 
care of nature in splitting the nucleus so that it shall be ac- 
curately divided between the tw r o new cells shows what an 
important function it plays in human life. 

The fibroblasts are now increasing at a rapid rate and are 
beginning to be crowded into the fibrinous reticulum. It must 
not be lost sight of that this net work is a well defined definite 
visible mass, spongy to the touch and red to the eye, because 
of included red blood cells. The whole structure is shortly to 
be swept away. How is this accomplished? Before nature 



22 CAPILLARY FORMATION. 

attempts it, she makes sure that the permanent structure 
destined to take its place is well established. This cannot 
be done without providing food and nourishment for the 
new cells to live upon. How is this brought there? When 
the sphere of fibroblasts is only one or two cells thick, they 
can readily be fed by the transudation to them of life giving 
plasma, but there is a limit to the distance to which this food 
can percolate between the cells, and it becomes necessary to 
establish channels to carry it toward the interior of the struc- 
ture. 

Capillary Formation begins by a head to tail union of 
a series of specialized connective tissue cells. The walls at 
the point of juncture break down, their included protoplasm 
guided by unknown forces, begins to circulate, and what was 
a simple series of end to end cells, has become a tunnel 
through which blood soon begins to flow. 

These Capillary "Tufts" are by a marvellous provision 
constructed in a loop so that they start and end in the liv- 
ing parts. If they coursed straight away into the new terri- 
tory, they would obviously soon become blockaded. Through 
their delicate endothelial walls along the whole course of the 
new vessel, but more particularly at the turn of the loop which 
is nearest the dead part, the plasma with its cell feeding ele- 
ments streams, and the products of metabolic cellular life are 
in like manner returned. 

It will often have been noticed how closely this micro- 
scopic picture conforms to the clinical findings when granula- 
tion tissue is treated. Such tissue frequently has to be cur- 
retted. This can be done without pain to the patient, because 
there are no nerves in the part. The hemorrhage, however, 
is always very brisk. This is because the tissue, as already 
described, is largely made up of young capillaries. 

At about this time, supposing a large number of successive 
spherical walls of endothelial cells to have arranged them- 
selves, like the many skins of an onion, about the scaffolding 
which had filled in the site of the extruded dead tissue, nature 
begins to realize that in the region of capillary development 
the scaffolding is no longer necessary. The builders, which 
were instrumental in creating the new and permanent wall, 



WET PRODUCTIVE INFLAMMATION. 23 

are now obliged to see to their own removal and to the destruc- 
tion of the net work which supported them. As is often the 
case with people, they are "turned down" by those whom they 
have helped. 

How does this process of removal of the scaffolding take 
place? The phagocytes, which it has at length been decided, 
are able to destroy living cells as well as dead, now turn their 
attention from quarreling with the invading horde of bacteria 
to carrying away the slowly disintegrating net work of fibrin. 
Many of these remarkable white cells have themselves died, 
either in conflict with the bacteria, or because of a failure of 
their food supply. The commissary department is as neces- 
sary to them as it is to soldiers in the field. When dead, it be- 
comes incumbent upon living phagocytes to carry them into 
the blood stream or to extrude them through the surface. 

Thus it is seen that these dead leucocytes, which had, when 
called upon to do so, assumed a phagocytic function, enter 
largely into the formation of what is called Pus. 

The white cells, the dead bacteria, the devitalized and 
toxin charged plasma, together with broken masses of tissue, 
basement substance and other refuse are carried away either 
by the plasma stream or by the remaining leucocytes. 

This process continues until the primary structure which 
was laid down immediately after the infliction of the injury 
is entirely removed and its place taken by the permanent tis- 
sue. This permanent tissue does not resemble the original 
tissue which was destroyed. When it has filled the wound 
and granulation is said to be complete, the region looks red 
and is only partially enervated. As time goes on, nerves, the 
most delicate structure in the human body, are gradually 
formed, so that sensation returns in part or in whole. The 
fibroblasts as. they grow older and following the inverse of a 
woman's career, grow thinner and thinner; they have an in- 
herent tendency to contract. This shrinkage of the granula- 
tion tissue is of vital importance in plastic surgery. Without 
it, the scars of wounds would always be red. Because of it, 
in from six months to a year, the capillaries are squeezed so 
that they no longer carry a similar volume of blood and the 
part turns white. 



24 DRV PRODUCTIVE INFLAMMATION. 

Such is the general history of the course of Wet Produc- 
tive Inflammation. 

Dry Productive Inflammation, it has been said, is seen 
typically in sclerosed arteries, in the well known "hob-nailed" 
liver and in contracted kidneys. This process, so insidious 
in its development and so fatal to life, is known to be un- 
accompanied by the production of pus, but its "dryness," or 
freedom from the products of accompanying exudative in- 
flammation is probably as already stated more or less relative. 
It is convenient, however, for the purposes of classification, 
to look upon the process as a dry one. 

In point of time, dry productive inflammation is infinitely 
slower than the wet. As is well known, it takes years for a 
liver to become cirrhotic or for arteries to sclerose, but the 
processes although differing much in time, are identical in 
the means of their execution. While one capillary tuft is be- 
ing formed in the dry type, a hundred are created, utilized and 
pinched out of existence in the wet. The one is a chronic 
process and the other is acute, but save for the presence of 
moisture in the one and its relative absence in the other, of 
slowness in the one, and of speed in the other, these so-called 
"types" are indistinguishable. 



SUMMARY OF CHAPTER II. 

(i) Inflammation, if looked at from a practical common 
sense standpoint and if shorn of the enormous amount of 
detail with which it is usually surrounded, is a very simple 
process quite easy to understand. The most common form of 
inflammation is called Simple Exudative Inflammation. This 
has nothing to do with the formation of new cells, and is 
characterized only by changes in the vessels. This form of 
inflammation gives rise to the familiar symptoms of many 
every day diseases such as colds and the like. It may, or 
may not be accompanied by granular change, or so-called 
"Cloudy Swelling," and there may, or may not be, slight 
destruction of cells. Cell death is frequently absent from this 
form of inflammatory change. 



SUMMARY OF INFLAMMATION. 25. 

(2) Productive Inflammation. This is not to be looked 
upon as a separate and distinct phenomenon apart from ex- 
udative inflammation. It is as a rule a continuation ; a ter- 
mination of the exudative process. It may be for conveni- 
ence divided into the "Dry" and the "Wet," these groupings 
being made in accordance with the degree to which it is 
accompanied by the exudative change. Productive inflam- 
mation has to do not with the vessels, as in the case of the 
exudative form, but with the cells. It produces fibrous scar 
from granulation tissue. The "dry" form is chronic and is 
accompanied typically by no dilation of the vessels. This form, 
it is, which is instrumental in producing the various cirrhotic 
and sclerotic changes, often called disease. 

(3) "Walled Off." This term, which is now so frequent- 
ly used, can be properly understood only as interpreted from 
its inflammatory relations. The "wall" is first round cells, 
and fibrin — later fibroblasts and fibrous tissue. It is a typical 
product of Productive Inflammation. 

(4) As the vessels are the important factors in exudative 
inflammation, so are the fibroblasts and other cells in produc- 
tive inflammation. 

(5) The so-called "phagocyte" is nothing more than a 
leucocyte which has been brought to the scene of the injury 
by a conscriptive process called Chemotaxis. They are capa- 
ble of destroying bacterial life, but their most important func- 
tion is to remove the solid products of inflammation, which 
when diluted form pus. 

(6) One of the easiest means of understanding the pro- 
cess of productive inflammation is to look upon the primary 
deposit in the part killed as a temporary scaffolding which is 
to be removed by nature's processes as the permanent cells 
take their position. An excellent illustration of the applica- 
tion of this stage of productive inflammation for the uses of 
surgery lies in its employment in operations where a portion 
of the tissue is removed and the sealed cavity allowed to fill 
with blood clot. This, as will be found later, is customarily 
referred to as "healing under Schede's moist blood clot." 

(7) The various processes of the inflammatory condition, 
although they are recognizedly diverse and in spite of the fact 



•26 EXTENT OF INFLAMMATORY PROCESS. 

that they extend over very wide fields, viz. — those in which 
the injury is inflicted, and those upon which its recovery takes 
place, must be recognized as part and parcel of one contin- 
uous interrupted process. Whoever looks upon them as sepa- 
rate cannot possibly clearly understand them. Furthermore, 
inflammation once clearly understood, constitutes by all odds 
the most important stepping stone to a basic interpretation 
of the science and art of surgery. It must be remembered 
that not a. solitary lesion exists which is unaccompanied by 
•one or other, or all of the forms of the inflammatory process 
-here described. 



CHAPTER III. 

THE ARTERIES AND THE VEINS. 

This chapter may be well introduced by a sketch showing 
the smallest, the least known and the most frequently asked 
triangle in the body. 

Fig. 2. 




A. /njcrtc? a.T O. 






nyfii.) 



4'**c£TeL ^e Oyupi 



ANEURISM. 

This is the most important surgical disease of the arteries. 
It will not be amiss to apply the scheme from Chapter I in this 
interesting lesion. 

Definition, — An aneurism is a pulsating swelling, filled 
with blood and communicating with an artery. 

Etiology, — The predisposing causes. 

Age ? Period of active life. 

Sex? Male more liable. 

Color? Said to be more common in the negro. 



28 PATHOLOGY OF ANEURISM. 

Occupation ? Hard labor. Traumatic aneurism was four 
times more common after the Civil War than it is to-day. 

Exciting Causes? Spontaneous aneurisms may be due to 
congenital defects or to the toxins of a hypothetical germ 
(syphilis). Traumatic aneurisms, usually seen on the extremi- 
ties and not infrequently in the popliteal space, are the direct 
result of trauma. Popliteal aneurisms are commonly said to 
be of frequent occurrence in grooms and liveried footmen who 
are obliged to dress in very tight pants and stand for hours 
at a time with the popliteal artery on the stretch from bend- 
ing their knees backward. This is an excellent illustration of 
an occupation disease. Fig. 3, shows the surgical relations of 
the popliteal space and emphasizes the depth at which the 
artery lies. 

Pathology, — Aneurisms result from the stretching of weak 
areas in a vessel wall. The gross pathology varies according 
to the type of aneurism. Spontaneous aneurisms are usually 
in the chest or abdomen, those occurring in the first situation 
being typically saccular whereas those found in the abdominal 
regions, particularly in the aorta, are generally elongate, or, 
as it is called, "Fusiform." A great many sub-divisions of the 
gross pathology of aneurisms have been made. One of these 
is the rare "Circoid" aneurism. In this the aneurism does not 
communicate with the artery but the entire vessel becomes 
aneurismal. It has therefore been defined as a "uniform dila- 
tation of an artery and all its branches." It is, in other w T ords, 
a varicose artery. 

Classifications of aneurisms have been based upon the 
shape of the sac; upon the method of infliction of the injury 
causing the aneurism, etc., but for practical purposes it is neces- 
sary simply to remember that they may be saccular, cylindrical, 
dissecting, spontaneous or traumatic. 

Minute Pathology, — This deals with the condition of the 
vessel wall at the site of injury and with the character of the 
contained clot. Occasionally the blood current splits an inner 
wall of the vessel, separating the coats and an aneurism results 
from the stretching of the outer wall. This forms a so-called 
dissecting aneurism. If all the coats of the vessel are not in- 
cluded in the sac wall it is known as a false aneurism. True 



SYMPTOMATOLOGY OF ANEURISM. 29 

Aneruisms on the contrary have all three vessel coats in the 
sac wall. 

Symptomatology ,— The detailed subjective symptoms of 
aneurism are of importance chiefly to the internist, for aneur- 
isms which lend themselves to surgical intervention, or as they 
have been called "Surgical Aneurisms" present little beyond 
the two characteristic surgical subjective symptoms of pain 
and disability. Medical aneurisms, as those which must at 
present be relegated to the internist have aptly been called, 
present a very characteristic and intricate chain of symptoms, 
which, it is not in the province of this book to discuss. An 
interesting one, for example, is the dilatation and subsequent 
contraction of the pupil in thoracic aneurism. 

The objective symptoms of surgical aneurism: — 

Inspection, — A pulsating swelling seen in the course of 
an artery. 

Palpation. Expansile pulsation. 

Percussion. Flat. 

Auscultation. Occasionally a "bruit." 

Differential Diagnosis. Again excluding the medical 
aneurisms, the question of differential diagnosis depends natur- 
ally on the position of the swelling. Let it be supposed that 
a swelling has appeared spontaneously in the popliteal space 
of an old syphilitic soldier. It might be a gumma ; it might 
be an osteosarcoma ; it might be a bursa from one of the 
numerous tendons in the neighborhood; it might be an aneur- 
ism. 



<JcLT-+OT* 



US 



Greet /V 5 

To7>7*fc*l 
/Irrcry 



/f77? C r 




Vastus Zxt. 



/Verve 






ftcrr? 



7%r7<+ti<L7 Vc'/3* 



Outer &Ca</ 



Fig. 3 

The relations and, particularly the depth of the popliteal artery, are shown 
in this figure. Note origin and course of external popliteal nerve. 



DIFFERENTIAL. 



3h 



Gumma. 



Sarcoma, 



Bursa. 



Aneurism. 



Slow growth. 



History of Tumor. 
Rapid growth. I Probably slow. 



Growth moderate- 
ly rapid, but on- 
set acute. 



Absent. 



Often present (as 
fracture). 



Injury. 
Absent. 



May be absent or 
present. 



Disease. 



Evidence of syph- 
ilis elsewhere. 
Onset slow. 



Absent. 



Cachexia. Onset 
rapid. 



Absent. Onset 
slow. 



Often present. 
(Some form of 
chronic irrit't'n) 



Previous Injury. 

May be present.- 



Arterio - sclerosis 
frequent. Onset, 
rapid. 



Typically present, 
either acute or 
chronic. 



Chancre. 



Previous Disease. 



May be metastatic 



Absent. 



Arterio - sclerosis, 
endocarditis, al- 
coholism, syphilis. 



Adolesence. 



Childhood. 



Age. 

Early middle age. 



Adult. 



Occupation. 



Negative. 



If present, not se- 
vere. 



Not marked. 



Negative. 



Always present 
often intense. 



Marked. 



Continuous over- 
work of one 
muscle. 



Pain. 

Negative. 

Disability. 

Moderate. 



Heavy work. 



Sometimes very 
severe. 



Marked. 



32 



DIFFERENTIAL.— Com i m ED. 



( rUMMA. 



Sarcoma. 



BlRSA. 



Aneurism. 



Often marked, 
particularly 
night headache. 



Nervous Symptoms. 

(Central.) 

Negative. Negative. 

Paresthesia?:. 



•Often marked. (Occasional. 



Absent. 



GENERAL PHYSICAL. 
Facies. 



Pale and anxious. Cachectic 



Negative. 



If present, due to 
sclerosis. 



Occasional. 



Drawn. 



Nutrition. 



Disordered. 



General discrete 
enlargement. 



Much disordered. 



Negative. 



No local enlarge- 
ment unless in- 
fected. 



Glands. 

Negative. 



Negative. 



Negative. 



May be absent. 



Negative. 



REFLEXES. 

Deep. 

Negative. 



LOCAL PHYSICAL. 

Inspection. 



Red swelling. 



Cool. May pul- 
sate (heave). 



Darker red. 



Normal color. 



Negative 



Palpation. 

Hot. May crepi- Cold. May pul- 
tate and pulsate sate (heave). 



Normal color. 



Hot. Expansible 
pulsation. 



DIFFERENTIAL.— Continued. 



33 



Gumma. 



Sarcoma. 



Bursa. 



Aneurism. 



Negative. 



Auscultation. 



Possible bruit. 



Negative. 



Typical bruit. 



LABORATORY FINDINGS. 

Tissue Section. 



Characteristie. Characteristic. 



Negative. 



COMPLICATIONS. 
Immediate. 



Negati 



Moderate increase 



Often pressure 
pain. 



Negative. 



Softening. 



Mediate. 



Fracture, Metas- AT ,. 
tasis and death. Ne S atlve - 



Remote. 

Disability. 



PROGNOSIS. 
Immediate. 



Negative. 



Lif e : Negative, 
K.I. improves. 



Almost surely fa- 
tal. 



Life negat ive, 
fuuction ques- 
tionable. 



Gangrene or rup- 
ture. 



Disability. 



Disability. Loss 
of extremity. 



May be fatal, func- 
tion impaired. 



K.I. or mixed. 



Disarticulation at 
hip. 



TREATMENT. 

Excision of sac. 



Mata's operation if 
possible. 



Undoubtedly much more might be said in attempting to 
give the differential diagnosis between these hypothetical cases, 
but it is not claimed that this differential is complete in all de- 
tails. Further application of the scheme will supply these if 



3.4 



CERVICAL ANASTOMOSIS. 



desired. As with Darwin's article on earth worms, very little, 
will remain to be said after the scheme has been thoroughly 
applied. Earth worms have been observed for the last thirty 
years, but nothing new has been added to the observations of 
the famous naturalist. 




{jtlCarofd. 



yJ <ujRc-r//cta.? 



"» c/«e/» CcT-wca. ? 






fair. 






J^nfe-r cos*** 7 ^ 



Fig. 4. 
Cervical Anastomosis. 



LIGATION. 



35 



Word schemes, however, are not the only ones which lend 
themselves favorably to a discussion of the arteries. Fig. 4. 
shows an invaluable diagrammatic scheme of the difficult and 
too-often asked cervical anastomosis. It is not artistic but im- 
mensely useful. One of the important differences between 
medicine and surgery is that medicine is given over very largely 
to diagnosis, whereas surgery is concerned more particularly, or 
at least to as great an extent, with treatment. An eminent 
authority has said perhaps not too wisely, but certainly concise- 
ly, that in general the medical treatment of a given condition 
can be summed up in three words : Nurse, Feed and Stimulate. 
This is obviously an exaggeration if applied too widely, but it 
serves to emphasize an important point. 

As a result of this essential difference between medicine 
and surgery, and partly because of the trend of the times, 
which is to leave medical cases more to themselves than was 
the custom until recently, it has been noted that particularly in 
the matter of aneurisms, the surgical treatment has always 
come in for a wide share of attention. 

Until a couple of years ago, very little change had been 
made. It was regarded as settled that no improvement could 
be looked for in the time honored methods of ligation or of 
extirpation. The classical procedures will be presented first 

and then the modern method of 
Matas. It is always a disagree- 
able chore, but one which has be- 
come a sort of classical entity, to 
learn the names of the surgeons 
who devised various methods, 
good, bad and indifferent, for the 
treatment of aneurism. It is al- 
most impossible to hold these with- 
out the aid of visual memory, and 
they can be conveniently kept in 
the mind's eye by learning to draw 
the accompanying sketch : 



l/}/vTyn.uS 




pttr?7a.j> 



S^SDO'f 



WftRDl?Oj> 



36 MEDICAL TREATMENT. 

Dawbarn has used a similar one in his lectures for many years. 
Hunter, it will be observed, tied proximally, one or more 
branches being given off between the position of the ligature 
and the aneurismal sac. Anel (like the German word meaning 
ass) tied in the soft and friable tissue too near the aneurism. 

Brasdor was as unfortunate in the choice of his position 
as was Anel, although there is no German word to commemor- 
ate his failure. In our own Bowery vernacular, however, he 
may be said to have had an over abundance of "brass" to expect 
a ligature placed as he placed it, to do any good. 

Antyllus, although he lived long before the two preceding 
gentlemen, was sufficiently courageous and intuitive to combine 
their methods, except that he went further and removed the sac. 

Phyllagrius, the old Greek, boldly opened the s*ac, as shown 
by the X in the diagram. 

Wardrop placed his ligature in exactly the inverse position 
of Hunter's. It was no good, and therefore "dropped off." 

The above mnemonics albeit inelegant have been found 
useful. 

All medical aneurisms and those of a surgical nature un- 
der certain conditions, are subjected to medical treatment. 
For aneurism, this is summed up in four words ; instead of the 
three which usually cover it. They are Rest, Starve, Purge 
and K. I. This is known as Tuffnell's Treatment. He was a 
sagacious Irish surgeon who hoped to dry the patient so that 
his blood would coagulate in the sac. 

There are several other methods which are only occasion- 
ally used. Perhaps the most important of these, — important 
because the changing fancy of surgical fashion appears to be 
bringing it into prominence once more, is compression by 
digetal pressure. 

Shepherd, of Montreal, has recently advocated the re- 
introduction of this method, although he admits that with the 
modern methods of aspetic technic, there is no very strong 
ground in favor of it. It is a sort of relay race, ten minutes 
being the limit of time which any one hand can hold a large 
artery. 

Tuffnell's treatment failing, efforts have been made in the 
case of certain inoperable aneurisms to increase the thickness 



MATA'S OPERATION. 37 

of the sac wall by causing the blood to clot upon it by local 
treatment. Of course, Tuffnell's treatment aims at increasing 
the coagulability of the blood by simply drying it up. The 
patient is desiccated and starved so that the heart becomes 
weak and the blood current very much diminished in force 
and rate. Slowing the pump also favors clot formation. 

Recently another means of increasing the coagulability of 
the blood which has been used in aneurisms, and particularly 
in pancreatitis, is the exhibition of immense doses of calcium- 
chloride; from 30 to 50 grains being given three or four times 
a day. 

All these efforts failing, bodies have been introduced into 
the sac upon which the fibrin could be whipped out as the blood 
rushed through it. The sac has been needled ; it has been 
treated with electricity ; it has been filled with hundreds of feet 
of watch spring steel ; it has had crowded into it many yards 
of fine malleable wire. The supposed difference between these 
two materials is that the spring coils itself upon the periphery 
of the sac as it is fed in, whereas the malleable wire makes a 
net work in every possible direction back and forth across the 
diameter of the sac, not being confined to the wall. 

The danger of these local methods of treatment is self 
evident. There is no means of safe-guarding against tearing 
loose and freeing into the blood stream particles of clot which, 
swept away to the lungs, cause pulmonary embolism and 
speedy death ; to the brain, death, hemiplegia or other lesions ; 
to the spleen, kidneys or other organs ; infarcts and various 
degenerative processes. These local methods of attacking the 
aneurism consequently are indicated only when its site renders 
it absolutely inoperable ; when all methods of cure by concen- 
tration and slowing of the blood stream have failed ; when the 
patients life is despaired of. 

Matas' Operation. This technic is being very generally 
introduced for the treatment of surgical aneurisms, and w r ill 
probably soon be adopted to cure certain medical aneurisms 
which are now practically hopeless. Very favorable reports 
are being made upon it. It represents by far the most im- 
portant advance which has been made in the surgical treatment 
of aneurism since the introduction of asepsis. 



38 PHLEBITIS. 

Preservation of the Lumen of the Artery is the object of 
the technic. For admirable details and illustrations of the 
operation, reference is best made to Brewer's Manual. The 
technic, in general, consists in the application of plastic sur- 
gery to the sac, by which means it is obliterated and the open- 
ing between it and the artery is closed. The lumen of the 
artery is preserved. Obviously it is the ideal method. When 
it was first advocated by its creative author, objection was 
made to it upon the ground that the extensive endarteritic 
changes, which in the nature of the lesion, must always be 
present, — often to the extent of depositing solid plaques of 
limestone — would in most cases prevent its employment. The 
"proof of the pudding, however, is in the eating," and the sug- 
gestion, although apparently based on sound mechanical rea- 
soning, seems happily to have lacked confirmation. It even ap- 
pears possible that this method as already suggested may soon 
enable surgeons to invade the territory of the medical man 
and take from him the treatment of many abdominal and 
thoracic aneurisms. (See "Surgical Treatment of Abdominal 
Aneurism," by C. B. Maunsell, British Medical Journal, June 
1 8, 1904). 

Large arteries are often cut accidentally. Brewer has de- 
monstrated experimentally (Surgical Laboratory, Columbia), 
that such w r ounds may be closed and the lumen of the vessel 
preserved. After stopping the blood flow and thoroughly dry- 
ing the part he winds the artery with a thin extremely adherent 
elastic bandage. 

PHLEBITIS. 

This is one of the most interesting conditions in surgery. 
Its sequelae are formidable ; its etiology in many cases is entire- 
ly unknown. 

It is a disorder to which the schemes of Chapter I, can 
most advantageously be applied. As before stated, there is not 
room to carry this out in a small book, but the point to be made 
is that by conscientiously following the scheme any one, after 
a little reading, can write or say all that is known on the sub- 
ject of phlebitis. The point to be striven for here as every- 
where else, is such a thorough acquaintance with the scheme 



PHLEBITIS. 3» 

that it naturally revolves in the brain like a rotary sifter, pick- 
ing out all the points bearing upon the subject matter and ex- 
cluding everything extraneous to it. Obviously, it is a ques- 
tion of time and patience to attain this end. 

What are the important points in phlebitis which naturally 
suggest themselves as the scheme is perused? 

Definition. An inflammation of a vein, due either to the 
toxins of germs, or to unknown spontaneous causes. 

Etiology. Femoral phlebitis in particular, often follows 
aseptic and successful laparotomies. Usually on the left side. 
Believed by Keen to be caused by mechanical pressure on the 
left common iliac vein. 

Pathology. Gross. If septic, full of decomposing blood 
clot. If sterile, vessel dilated and clot may be incomplete. 
Minute. If septic crowded with the specific germ. 

Symptomatology. General. If septic, evidences of sep- 
ticemia. Local. If septic, blue line, rat-tail feel. 

Differential Diagnosis usually to be made between the two 
varieties. 

Complications. If septic ; those of septicaemia, Swelling 
of extremities. 

Prognosis. If septic, may cause death. In any case often 
impairs function of extremity for a long period. 

Treatment. Medical, nurse, feed, stimulate. 

Surgical. Palliative ; mild case ; elevate, rest, ice bag, 
elastic bandage. Radical ; severe case, septic, excise and drain. 

In this particular case the sub-schemes for giving subjec- 
tive symptoms and differential diagnosis are seen under ordin- 
ary conditions not to be necessary, but the} may be applied to 
phlebitis as to anything else, if it be so desired. 

Summary of Phlebitis. It may be septic or aseptic, the 
latter form being one of the most dreaded sequels of aseptic 
laparotomies. It is on a par with pulmonary embolism in this 
respect, for it steals in after the door has apparently been 
closed. Like varicocele, this form is usually on the left side, 
and as in the case with varicocele, is probably due to the 
mechanics of the anatomical structure. The septic form is oc- 
casionally a sequel of operations ; but may follow any dirty 
wound. It is common in the internal jugular, that vein having 



40 GRAVITATION DISEASES. 

been infected through contiguity of the lateral sinus to a germ 
laden mastoid, or by continuity with the facial vein. (See Fig, 
13) 

VARICOSE VEINS. 

These interesting lesions are the bread winners of the 
young surgeon. They cause an immense amount of human 
suffering. Their etiology is simple. Shaler has said, that as 
in the case of hernia ; of all the displacements of the uterus and 
ovaries, and a host of similar lesions, varicosities arise from 
man's getting too ambitious and rearing up on his hind legs to 
walk. This class of lesions, from which the animals are prac- 
tically immune, could well be classified under the general term 
"Gravitation Diseases." 

The three most important varicosities occur in the leg, 
in the pampiniform plexus of the spermatic cord ; where they 
are familiarly known as varicocele, and in the inferior and 
middle hemorrhoidal plexuses, where they are called hemorr- 
hoids. 

Practically these are self-evident, and except in the case 
of varicocele, rarely have to be differentiated. Their treat- 
ment consequently is of first importance. In the legs, this de- 
pends somewhat upon the type. Suppose a diffuse varicosity 
to exist all below the knee giving that red, nasty, swollen, 
boggy leg, so characteristic of the "hobo" and of the worn out 
cook. As Jacobi says: "What to do?" Make a boot of the 
patient's own skin by cutting a circle around the leg, just dis- 
tal to the knee. Avoid the important cutaneous nerves and 
cut to the muscles. Tie the vessels as you cut, and on com- 
pleting the section, suture the skin. This is called "Schede's 
operation." It blocks every cutaneous vessel and forces the 
circulation into the deep veins. 

If the lesion be characterized by swelling of the distal por- 
tion of the long saphenous and with dilatation and tortuosity 
of the vessel in the upper part of its course, the tortuosities may 
be excised and the upper segment treated by subcutaneous 
ligation or by removal of small sections along the course of the 
vein. For treatment of proximal long saphenous varicosity, 
Fowler has devised a unique method. He ligates at a chosen 



TREATMENT OF VARICOCELE. 41 

point six odd inches distal to the saphenous opening and again 
ligates between the opening and the first ligature. At this 
point he cuts the vein and frees it enough to grasp it with a wet 
towel. He then, by a sudden jerk, pulls the severed section 
of the vein, hook, line, bob and sinker, clean out of the tissues. 

Every one must remember the pictures in school text 
books of physics which show Torricelli's famous experiment 
in which he burst a tremendously powerful cask by screwing 
a pipe into it and pouring water in at the top of the pipe. By 
this means and without a very high pipe, such a cask can be 
blown to pieces. No wonder the veins dilate, for in getting up 
upon our hind legs, we illustrate admirably the Torricellian 
principle. 

Varicocele. This lesion has until recently been treated to 
a large extent by subcutaneous ligation. It is recounted of 
a famous French surgeon, that on one occasion a patient called 
at his office and the surgeon found him to be suffering from a 
bi-lateral varicocele. Esculapius was about to go to the opera, 
but hastily taking his needle, after injecting a little cocaine, he 
threw a ligature about the parts on both sides. The varicocele 
promptly disappeared, but in six months time the testicles had 
atrophied ! On discovering this, the patient bought a revolver, 
went to the office of the surgeon and shot him dead. He was 
arrested, tried and promptly discharged by a court on the 
ground of "justifiable insanity!" 

Accidents similar to this have combined to put a quietus 
on sub-cutaneous ligation for varicocele. It is contrary to the- 
spirit of surgery to work in the dark. 

The open operation here as elsewhere is to be preferred. 
Most surgeons advocate placing the incision as high as possible 
so as to avoid cutting the tissue of the scrotum which is most 
difficult to sterilize. The important points are to note the 
vas deferens by its rat-tail like feel ; to remember that the three 
arteries are so small that their pulsation can hardly be felt ; to 
note that the offending veins are usually separate and distinct 
from the normal veins of the vas ; to tie above and below ; to 
excise the included inch or more of the plexus and to make 
an internal suspensory by approximating the cut butts together. 

Hemorrhoids. The easiest way to treat these varicosities- 



42 TREATMENT' OF HEMORRHOIDS. 

efncac ously is to put an angiotribe on them for a few minutes. 
This instrument is a giant forceps designed to exercise a pres- 
sure of from one to 2,000 pounds to the square inch. The tis- 
sues embraced in its jaws are compressed to the thinness of the 
finest sheet of tissue paper. This treatment is particularly 
suitable for the single external hemorrhoid, for it can be done 
very conveniently under local anesthesia. 

Many people dread a general anesthetic more than they 
do an operation. For severe cases of internal hemorrhoids, 
"the suggestion by Tinker that the entire perineal region may 
be completely anesthetized by using massive infiltration of a 
half per cent, of eucaine in the neighborhood of the great 
ischiatic tuberosity where the internal pudic and long pudendial 
nerves course about the bone will be of importance in further- 
ing the treatment of these cases. If prostrates can be painless- 
ly enucleated by this method, surely hemorrhoids may be 
similarly treated. (See illustration under Prostatectomy.) 

The clamp and cautery is probably the favorite method of 
treating hemorrhoids. 

Another widely employed technic is to seize the apex of 
the tumor with a blunt clamp, to circumscribe its base with a 
sharp knife through the mucous membrane, to transfix it with 
a needle bearing heavy pedicle silk; to cast a Staffordshire knot 
over the growth, to tie it so tightly as if possible, to kill the 
nerve endings, and finally to cut off the apex as near to the 
suture as is safe. This is known as ligation. 

In the execution of this technic, the flaw is apt to He in 
the fact that it is almost impossible to tie the suture tight 
enough to kill the nerves. If these live, for several days after 
the operation, the surgeon had better leave the patient exclu- 
sively to the nurse, for the pain makes the remedy worse than 
the disease. Injecting the veins with irritants and escharotics, 
such as equal parts of tincture iodine, glycerine and phenol, 
is widely practiced by quacks and constitutes, in the hands of 
some of these men a useful, although admittedly dangerous 
palliative treatment. 

The Medical treatment of hemorrhoids is satisfactorily em- 
braced by the four words, nurse, feed, stimulate and bidet. 

Fig. 6, show r s the veins of the face and neck. They are 



NEVI. 



43 



frequently asked for in hospital examinations. The temporo- 
maxillary sinus, when varicose, constitutes a very evil lesion, 
its removal being extremely difficult. 

■-:. r* 



~h«y 



I»4 Labial 



3. Jo7lSl}la.r 

■2. ^narynqeo.). 
q JhyroictS 



Trr? 

Jujula 




fa* an* Tisi; 



Fro. 



Nevi. These dilatations occupy a mid -position between 
the arteries and the veins, by virtue of their occurring either 
in the small continuations of these vessels, or else actually in 
the capillaries which connect them. They have been con- 
veniently divided into capillary and cavernous. The capillary 
form is best known in the familiar "mother's mark." All 
"mother's marks" are, however, not due to capillary dilatations, 
some being caused by pigmentary deposits. These dilatations 
are usually treated in one of two ways. They are either 
excised, and the part is skin grafted, or else they are subjected 



44 VENOUS ANASTOMOSIS. 

to electrolysis. The negative needle of a galvanic battery is 
run longitudinally its full length into the growth. The elec- 
trolytic action destroys a number of cells in the near region of 
the puncture. Productive inflammatory changes take place, 
and as explained in Chapter II, the gap is presently filled with 
granulation tissue. At no distant time this contracts, and, 
clinically, where once was a disfiguring red blotch, will be 
seen a fine white line. A multiplication and an irregular cross- 
ing of these fine white lines eventually destroy the growth, 
enough capillaries being left to preserve the normal skin color. 
The technic is tedious to the operator and expensive to the 
patient. 

Cavernous Nevi are lesions which sometimes threaten life. 
They have an evil habit of growing with such rapidity that 
they may be difficult to differentiate from a rapidly growing 
sarcoma. They occasionally yield, when inoperable by the 
knife, to prolonged treatment by electrolysis. Bubbles of hy- 
drogen can in these cases be seen, when the electrical action is 
going on satisfactorily and when the needle is suitably placed, 
coursing at the rate of one or two to the second through the 
dilated and about to be destroyed veins. 

Wyeth has recently devised a characteristically ingenious 
and simple method for the treatment of these growths. It 
consists in the introduction of boiling water directly into the 
tissues, the water being boiled by a lamp held under a syringe 
which holds half a pint to a pint. This process is much more 
rapid than electrolysis, and it is safe if care be taken not to 
introduce enough boiling water to cause necrosis. In other 
words, not more tissue should be destroyed at a time than 
can be taken care of by the phagocytes and the plasma, without 
the necessity of the organisms pushing the devitalized ma- 
terial out through the surface. 

The knowledge of the paths by which the blood may 
return when the portal system is obstructed is an important 
aid in establishing many diagnosis. It is a frequent hospital 
question and is therefore given. (From Gray) 

(i) By anastomosis of mesenteric veins with superficial 
abdominal. 

(2) Of phrenic and gastric veins with those of Glisson's 
capsule. 

(3) Of superior hemorrhoidal, inferior mesenteric and 
internal iliac. 

(4) Gastric and esophageal with azygos minor. 

(5) Left renal and intestinal. 



CHAPTER IV 



NERVES, MUSCLES, TENDONS AND BURSAE. 



LUMBAR PLEXUS. 



Fig. 7. 



From upper four Lumbar 
Nerves. 

The 1st Lumbar splits into 
two; the 2d, 3d and 4th split 
into four each. 

The 2nd division of I., 
and the 1st of the II. unite. 
(Genito-crural) 

The 2d division of II., and 
1st of III. unite. (External 
cutaneous) 

The 3d division of II, and 
2d division of 3d, and 1st di- 
vision of IV. unite. (Ant. 
crural) 

The 4th division of II., the 
3d division of III. and 2nd 
of IV. unite. (Obturator) 

The 4th division of III., 
and 3rd division of IV. unite. 
(Accessory obturator) 
The 4th of the IV. unite with V. (Lumbo Sacral Cord) 
The Mnemonic for this is : 

"If I get examined, all's over. Oh!" 

The two most interesting problems in the surgery of 
nerves are suture and transplantation. 

According to very recent views, the outlook on suturing 
a nerve many months after its section, is almost as good as if 
the operation had been done immediately after the infliction 




46 NERVE SUTURE. 

of the injury. This is not in accordance with the older teach~ 
ing, which was that there is very little use in attempting to do 
anything with a severed nerve, unless it can be operated on 
immediately after being cut. This recently demonstrated abil- 
ity of the nerve to re-establish its function, even if united long 
after the reception of the primary injury, seems to show that 
the much dreaded degeneration is not so grave as was formerly 
supposed and suggests that function returns in some other way 
than by the actual re-establishment of the axis cylinders. The 
conclusion from these recent observations is that no case of 
peripheral nerve injury should be refused operation simply be- 
cause the opportunity to unite the divided ends comes at a 
late hour. In any event, whenever the union is made and 
whatever the process of repair, return of function, which may 
be either incomplete or complete, comes at best only after 
months of patient treatment with electricity, massage and 
hydrotherapy; one and all. 

Another conclusion, which is of very great importance is 
this, viz. — no attempt should be made to unite the ends of a 
divided nerve in case the wound is known to be dirty. Inas- 
much as a moderate delay or even a prolonged delay appears 
not to have the profound importance which was formerly as- 
cribed to it, some surgeons now advocate postponing the 
operation until after the active manifestations of the inflamma- 
tory reaction have cleared away. 

The attempt to replace a destroyed segment of human 
nerve by grafting an equal length of animal nerve has failed. 
So it did in the case of bone grafting. The body does not take 
kindly to any form of graft, except skin graft ! Decalcified 
bone tunnels, and a host of similar devices, the supposed pur- 
pose of which is to keep the pathway open for the axis cylinders 
to grow along, have also proved failures. They should proba- 
bly therefore, be entirely abandoned and recourse had, in the 
event of destruction of a segment of the nerve, to bone resec- 
tion. This of course applies only to wounds of nerves on ex- 
tremities, and although in the arm it shortens the "reach," this 
is justifiable except of course among a certain class of athletic 
gentlemen. 

Transplantation has lately awakened a widespread interest, 



NERVE TRANSPLANTATION. 4T 

because it appears that the possibilities before it are as yet only 
half surmised. As has often happened before, supposed ad- 
vantages of this technic may have been exaggerated. 

The present status of transplantation, however, is such 
that a thorough knowledge of how the technic is applied; its 
indications, and its limitations is desirable. So far, the most 
important application of the principle has been made in cases 
of paralysis of the seventh. The process is a simple one. 
Given a case of facial palsy, what can be done for it? Ob- 
viously it can be massaged, electrefied and hydrotherapized, 
but as is well known, if the disturbance be centrally situated 
absolutely no good will follow. Until very recently, it was- 
held that the centres of the cranial nerves differed widely from 
each other. They certainly send out impulses having utterly 
different characteristics. The medullary centers have become 
peculiarly specialized, in that for example, one interprets hear- 
ing, while another almost adjacent to it, controls the muscles 
of the tongue. The one is a higher class of work than the 
other. How can it by any possibility be that one of these 
little bunches of cells, after a short education, can assume the 
functions of the other? Whatever be the answer, the fact re- 
mains that if a portion of the hypoglossal nerve, as it courses 
in the neck toward the tongue, be grafted into a centrally 
paralyzed seventh nerve, the patient will, under favorable con- 
ditions, regain facial control. Y\ nen first done, it was not ex- 
pected that anything would happen. As is sometimes the 
case, however, the unexpected did happen and the control of 
the muscles of the face was assumed by the center of the 
twelfth. This center did its own work and that of the seventh 
as well. What an interesting series of possibilities this 
awakens. It is true that both these centers have to do primar- 
ily with the creation of motor impulses, but if such a switching 
of motor centers is possible, may it not untimately lead to a 
switching of the special sense centres as well? Will, for ex- 
ample, the first nerve ever be made to assume the functions of 
the second, thus giving sight to the blind? 

MUSCLES. 

A strain is an injury produced by over-stretching a muscle, 
A sprain is also an injury produced by over-stretching a mus- 



48 CONTRACTURES. 

cle. Each of these may occur in the ligaments. The first 
may be said to be distinguishable only with a microscope, or 
perhaps not even by such delicate means, whereas the second 
is always accompanied by a macroscopic, or physical tearing 
of the fibres. Strains are more apt to occur in muscles than 
sprains, which are usually seen in the neighborhood of joints, 
the ligaments being torn. 

Musclts are apt to undergo calcification. It is well to 
note that this change differs from ossification. The one is a 
•dead process, the other a living. Ossification, while not so 
common as calcification in the muscles, is not by any means 
unknown. Rider's bone is a plate forming in the adduct or 
longus and is frequent among the cavalry men. Drill 
Done occurring in the deltoid muscles is occasionally seen 
among infantry- men. These lesions are the result of chronic 
irritation and are grouped under the general term of occupation 
diseases. 

Muscular Contractures are of great interest and impor- 
tance. Their treatment forms a large portion of the work of 
the orthopedic surgeon. They are of two distinct types, spas- 
modic or relaxing and non-relaxing. Spasmodic contractures 
are often called contractions. 

The most practical way to differentiate contractures is 
to give the patient chloroform. The first type is seen typically 
in those cases where Nature endeavors to make splints out of 
the organism's muscles, as for example, to protect a joint in- 
flamed with disease from harmful motion. The rigidity of such 
muscles is so great and the tone of the tension so constant 
that it is often impossible, except under an anesthetic, to tell 
whether such a stiffness is of the transitory or permanent type. 
Naturally, if transitory, when the element of pain, which symp- 
tom calls this muscular tone into action, is obliterated, the mus- 
cle relaxes, and the condition is seen to be spasmodic. Muscles 
in a state of chronic tonicity are apt to become permanently 
shortened. If no relaxation occurs a non-relaxing contraction 
is demonstrated. 

Myotomy or Muscle Section is indicated in non-relaxing 
contractures. Familiar examples are, section of the sterno- 
mastoid for spastic torticollis, or of the flexors and adductors 
in late stages of coxitis. Tenotomy usually takes the place of 
myotomy. 

The fasciae are very liable to degenerative changes. As 
elsewhere in the body, so in the fasciae fibrous tissue tends on 
slight provocation to become very thickened, or sclerosed, 1 as 
it is called. It will be remembered that this process has been 
described in Chapter II, as dry productive inflammation. 



DUPUYTREN'S CONTRACTURE. 49 










Fig. 8 

One of the most interesting, as well as most common, con- 
tractures of fasciae, is what is called Dupuytren's Contracture. 
It occurs in the palmar fascia. It has nothing to do with the 
tendons. It is a superficial lesion. It is infinitely more com- 
mon in men. It is characterized by a gradual closing of the 
fingers, which are held in a pathognomonic position as though 
by bands of steel. As it is often bi-lateral, a central cause has 
been suggested for it. Probably chronic irritation favors this 
sclerosis, although it is by no means uncommon among men 
who have done but little manual labor. 

The figure shows that the hand assumes, (no doubt for the 
convenience of ones memory), the well known position of 
Papal Blessing or Apostolic Benediction. Were it not for this 
obliging resemblance, it would be very difficult to remember 
the fact that the lesion occurs almost entirely in the fascia lead- 
ing to the ring and little finger. 

Treatment. The open and the closed methods are advo- 
cated. By the open, some cocaine is introduced and a longitu- 
dinal section is made directly over the steel like band of fascia. 
This band is tensed by traction on the closed finger. After a 
little dissection it easily comes into view, is sectioned proxim- 
ally and distally, and as much as possible of it is removed. The 
subcutaneous method consists in making a series of sections 



50 



SENSORY NERVES, UPPER EXTREMITY. 



of the tense band with a fine tenotome. . It occasionally gives 
good results, but as a rule is to be utterly condemned because, 
as time goes on, more sclerosed tissue grows as a result of the 
traumatism and irritation of the operation. Tenotomy is, to- 
day, practically the only closed operation that has survived. 



Fig. 9 



JJlTlFi 







7?e?-t/e c*/«/s severe^ 





Fig. 10 



51 



DIFFERENTIAL. 



Dupuytren's Con- 


• Ulnar Section. 


Median Section. 


Burn Contract- 


tracture. 






ure. 




History 


of Injury. 




Absent. 


Cut near wrist us- 
ually. 


Cut near wrist us- 
ually. 


Burn of severe de- 
gree. 




Disease. 




Onset extremely 








slow; begins lit- 


Onset immediate. 


Immediate. 


Moderately slow. 


tle finger. 










S] 


iX. 




Male. 


Male. 


Male. 


Negative. 




DlSAI 


SILITY. 




Unable to let go 


Unable to grasp 


Small objects can- 


Depends on extent 


after taking hold 


objects normal- 


not be picked 


and position of 


Sensation nor- 


ly. Loss of sen- 


up by thumb 


the burn. If 


mal. No wast- 


sation as in Fig. 


and fingers. 


nerves were de- 


ing. Posture : 


10. Atrophy of 


Loss of sensa- 


s t r o y e d , the 


typical; aposto- 


hypothenar, 


tion as in Fig. 10 


parts supplied 


lic blessing. 


eminence mark- 


Atrophy of the- 


by them will un- 




ed. Posture: 


nar eminence 


dergo the four 




typical; claw- 


marked. Post- 


characteristic 




hand. 


ure: typical. 


changes cited 






Ulnar flexion with 


below. Posture: 






extension of 


atypical. 






wrist and fin- 








gers. 





Note four important points in diagnosis of nerve section : 
Atrophy, Paralysis, Anasthesia, Posture, 

Note also that every nerve which crosses a joint supplies 
filaments to all the soft parts as well as to the hard. 

TENDONS AND TENDON SHEATHS. 



Tendons are more frequently the scene of operative inter- 
vention than muscles. This word is used advisedly instead of 
interference, because the surgeon does not "interfere." The 



52 TENOSYNOVITIS 

Tendon Sheaths are exquisitely delicate sacs much like dimin- 
utive pleurae. They are subject to inflammatory changes, not 
dissimilar to those which occur in the great sac. One charac- 
teristic sign of pleurisy is the see-saw friction rub heard as the 
patient breathes. It can sometimes be felt. Similarly, in the 
small sac, dry inflammatory processes go on. The smooth 
bearing surfaces usually so well oiled and presenting infin- 
itesimal obstruction to motion, become dry and corroded. 
On pulling the tendon back and forth after this change has 
taken place, they emit a grating sound and transfer what is 
called a fremitus to the hand. This is known as tenosynovitis. 
It is usually an acute or sub-acute lesion, and it occurs fre- 
quently in the tendo- Achilles. ''Tender feet" who have over 
indulged in walking often fall a prey to it. 

Chronic teno-synovitis is present in most cases of tuber- 
culous joints. It is characterized by an increase in the size 
and number of the inflammatory particles characteristic of the 
acute form. These may gradually grow until they finally be- 
come detached. They are soft at first but ultimately undergo 
calcareous degeneration. After this they are known as rice- 
bodies. Most of these formations contain in their center 
tubercle bacilli. It frequently happens that the chronic form 
of teno-synovitis as in the case of many other lesions, usually 
originates in the acute. Obviously the chronic form is amen- 
able only to operative treatment. 

Tendons often have to be cut to correct muscle contrac- 
tures. This is done subcutaneously. Repair of the part takes 
place under Schede's moist blood clot referred to on page 25 
Consequently great care should be exercised not to allow the 
dressings to press out the blood clot, failure of which to organ- 
ize means loss of function in the part. 

A felon is an acute inflammatory process in the distal 
phalanx of a thumb or finger. It begins on the palmar surface. 
It is typically a periostitis, although the other soft parts, par- 
ticularly the tendon sheath, may be primarily involved. Treat- 
ment consists in section over the point of the greatest pain 
through the periosteum. The indication for this section is 
not the presence of pus but the symptom of pain. 

Ganglion. The lay name for this is weeping sinew. 



BURSAE. 53" 

Ganglia are now thought to have no connection at all with the 
tendon sheaths, but to take their origin from the synovial 
fringe of the neighboring joint. They are therefore a form of 
distention cyst. They may be treated by rupture subcutan- 
eously or by aspiration or excision. 

Tendon Transplantation. This is often useful in cases of 
acquired paralysis of the extremities. It has been employed 
more particularly upon the foot. It consists, for example, of 
inserting a slip of the tendon of the peroneus longus into that 
of the tibialis anticus. It is of value only in rare cases where 
there is a healthy muscle near a paralyzed one. 

BURSAE. 

The lesions of the bursae are classed as occupation 
diseases. They are the result of exudative and productive in- 
flammation. Morphologically they are distention cysts caused 
by long continued pressure. Child believes them to be essen- 
tially protective rather than pathologic in nature. From hoary 
antiquity we have inherited the following old classics : 

House Maid's Knee or pre-patella bursitis ; Miner's Elbow; 
rarely seen in this country, but frequently in England and 
Wales, where the coal seams are so narrow that the men are 
obliged to lie on their sides to use their picks. As they pick, 
the elbow rotates back and forth on the Olecranon process 
and the bursa enlarges. Coachman's Bottom. This, on ac- 
count of the hard seats which the liveried flunkies of the British 
nobility are obliged to sit upon, combined with their tight 
pants, arises on the tuber ischii. It is rarely seen in this coun- 
try because of adequate upholstering. 



CHAPTER V. 
LYMPHATIC VESSELS AND THEIR NODES. 




Fig. 11 

Shows the group of cervical glands typically involved in syphilis. 
This figure is designed also to show the cervical triangles as 
simply as possible. 



ACTION OF THE NODES. 55 

The relation of the lymphatic vessels to diseases in general 
and particularly their influence upon the metastatic distribution 
of carcinomata make them of very great importance surgically. 
A thorough knowledge of the distribution of the lymphatic ves- 
sels which drain the tongue, the breast and the uterus is a 
sine que non for all, but most particularly for those wishing 
to rank in a hospital examination. The character of the opera- 
tions on these important parts is governed entirely by the dis- 
tribution of the lymphatics. 

The glands may well, for purposes of convenience, be 
looked upon as nature's sieves. They protect the body from 
germ infection and other dangers, and are therefore of great 
surgical importance. They do not, however, bear as intricate 
a relation to surgical pathology and treatment as the vessels. 

The lymphatic vessels play a very important part in the 
distribution of germ toxins as well as of the germs themselves. 
The glands or nodes are thought to filter out the germs them- 
selves much more efficaciously than their chemical products, 
although it is well known that in passing through these bar- 
riers of infection, the toxins are greatly moderated in their 
virulence. Reciprocally the glands are enlarged and often per- 
manently damaged. It is, however, in the protection of the 
body against invasion of the actual germ bodies themselves 
that the glands show to the best advantage. Their well known 
splenic reticular structure seems to have been specially devised 
to entrap the invading vegetable hordes. When a germ is 
lodged in the gland, there is plasma enough and leucocytes 
enough in this vascular organ to inhibit its development if not 
actually to kill it very shortly after its lodgement. If the dose 
of infection at the primary wound, supposing it to be on an 
extremity, is not sufficiently great to entirely overwhelm the 
lymphatic nodes, they will sieve out the intruder to the entire 
protection of the general organism. If, however, the dose is 
overwhelmingly large, there is naturally a limit to the number 
of germs they can accommodate, and the result is that, like 
sponges filled with water, they can take no more. The germs 
•then pass on and are swept either into the general vascular 
stream where the great lymphatics join the veins, or into the 



56 TERMINATIONS. 

inner breast works as they might be called, of lymphatic nodes, 
unless this last line of defense has already been passed. 

This introduces the very important subject of lymphangitis 
and lymphadenitis. 

This is not an inopportune time to grind out these various 
endings. Very few students know them, but it is a blessing 
to realize that if the half dozen odd terminations are once 
memorized and thoroughly understood, they can be applied 
throughout surgical pathology. 

For nerves, for the stomach, for tendons and so on down 
the line, these terminations will be used. 

Lymphangitis. "Itis" means inflammation of. Seen 
also in appendicitis, gastritis, otitis,, etc. 

Lymphadenoma. "Adene" in Greek means a gland, so 
that this termination means a lymphatic grandular swelling 
devoid of inflammatory reaction. 

Lymphadenitis. Here the two terms are combined. The 
"itis" showing that the enlarged gland has undergone inflam- 
matory change. 

Lymphangitis. "Angi" in Greek means a vessel. This, 
therefore signifies an inflammatory condition of the lymph ves- 
sels. 

Lymphangiectasia. "Ectasia" in Greek means dilatation. 
Therefore this term as applied to the lymphatics means that 
the lymphatic vessels are dilated. 

Lymphangiorrhaphy* "Rhaphy" in Greek means a line of 
union. It is seen in the "median raphe," a term familiar to all. 
Now raphe means also to sew. Whenever it is suffixed to a 
word, therefore it means that the parts have been sewn to- 
gether. For example, enterorraphy means a sewing of the gut. 
This naturally is rarely practiced in the case of lymphatic ves- 
sels, because they are too delicate to sew together, but at- 
tempts have been made to suture the thoracic duct. 

Lymphangiostomy. "Stoma" means mouth. (Kindly re- 
member that this has nothing to do with stomach). Stomatitis 
is an inflammation of the mouth. If you make a mouth on a 
thing, it implies that you have made a hole in it for good. This 
differs from a temporary opening, which will be considered in a 
moment. If it were desired to make a fistula to drain the 



DUCT LESIONS. 57 

lymphatic duct, experimentally, for example, this would be a 
lymphangiostomy. . It will readily be noted that this operation 
is not practically used on the lymphatic vessels, but it is intro- 
duced here to show that theorectically all these terminations 
can be applied at will to almost any organ. The familiar opera- 
tion in which this termination is used, is one done on the stom- 
ach and it is therefore called gastrostomy. 

Lymphangiotomy. "Temno" in Greek means to cut. If 
you cut into a vessel, you make an opening into the lumen. 
Usage has determined that this term shall apply to a temporary 
opening in contra- distinction to the one just considered in 
which ''stoma" is used, which implies the making of a perma- 
nent opening. This is illustrated particularly well on the 
stomach. A gastrotomy is done on a man who has swallowed 
his false teeth. It is immediately closed by gastrorrhaphy. If 
his esophagus is destroyed, however, he requires a gastrostomy. 

Lymphangiectomy. "Ectomy'' is derived from two Greek 
expressions "ec" and "temno" "ec," meaning out, and "temno," 1 
to cut. "Angi," here, as elsewhere, means vessel. Therefore 
this long word means simply a cutting out of a lymphatic ves- 
sel. In practice this is rarely deliberately done, the fine lym- 
phatic vessels being removed with masses of other tissue. 
The terminations are used very frequently to denote operations 
on other viscera. For example, neurectomy, is practised for 
the relief of sciatica ; enterectomy, a removal of a section of 
the enteron or gut is frequently done for strangulated hernia. 

Lymphedema. From the Greek "Oidos," a swelling. 
This means a transudation into the areolar tissue of lymph. 
It is generally due to a blocking of the vessels. It is distinct 
from venous edema in that it is solid. 

Returning from this excursion into etymological fields, it 
is interesting to note what definite relations lymphatic vessels, 
bear to disease in general. 

Filariasis. This is the general term for a series of symp- 
toms which until quite recently were regarded as having separ- 
ate entities. They are called into being by the presence of an 
animal parasite called filaria sanguinis hominis, which means 
the thread worm of man's blood. It is 1-80 of an inch long. 
The embryos are harmless, but the adults produce a train of 



58 LYMPHADENITIS. 

symptoms, the like and diversity of which is not paralleled by 
any other known organism. One of the most important of 
this series is 

Elephantiasis. This disease is rarely seen outside the 
tropics. It is a productive inflammation, due to the presence 
•of the filaria in the lymphatic vessels. This occludes the vessels, 
and ultimately they either burst or degenerate into solid strings. 
'So terrible is this disease in its ability to cripple and render 
useless great numbers of men and women that immense prizes 
of money await him who is fortunate enough to discover its 
remedy. 

Chyluria. This symptom is also produced by the filaria. 
The urine looks like milk. The pathology is not yet under- 
stood. 

Lymphadenitis is a commonly seen swelling of the nodes. 
It is due, as already stated, to the snaring of pyogenic germs 
in the meshes of the node and to the irritation of its paren- 
chyma by their toxic products. The parenchymatous cells are 
the cells which do the specialized work of an organ. They are 
supported by the interstitial or frame creating cells which unite 
to hold them in place. Six years ago, the pus producing organ- 
isms were supposed by many to be confined to the three varie- 
ties of the streptococcus and the staphylococcus, viz. — the 
albus, the aureus and the citreous. This list has now been 
lengthened to over thirty. The best way to remember it. is 
to learn the germs that do not produce pus. Prominent among 
these are the parasites of tetanus and diphtheria. 

Lymphadenitis may be acute or chronic. It is not uncom- 
mon in the groin. If a patient is found to have a swelling of 
the glands below Poupart's ligament, look for a sore on the 
foot. If the cross bar of the lymphatic T is involved, look for 
venereal infection. Acute lymphadenitis, particularly when the 
inflammation is localized either in one gland or in glands which 
are close together, is sometimes called bubo. Bubo is from the 
'Greek "Boubon," meaning groin, but the term is also occasion- 
ally used to denote an inflammatory condition in glands situ- 
ated elsewhere. 

The treatment is palliative or radical. If the infection has 
been of such a degree and nature as to kill the gland, ice bags 



LYMPHATICS OF FEMALE GENITALS. 



59 



and rest will do no good. These agents, however, should al- 
ways be employed, and it is well to remember that in practically 
all cases of acute inflammation, cold is indicated during the 
first 36 hours and moist heat after that time. Moist is much 
more efficacious than dry heat. 

The radical method of treatment consists in free incision 
and drainage. The after-treatment is very tedious. Attempts 
to heal these lesions rapidly by the application of the principle 
of Schede's moist blood clot have been successful. The technic 
after opening and curetting is simply to swab the cavity out 
with pure carbolic acid, douching it immediately with alcohol. 
This stops further action of the acid. This method of treating 
abscess cavities has recently been widely adopted by many New 
York surgeons. It has been used with favorable results in 
thousands of cases at the Hudson Street Hospital. After irri- 
gating with the alcohol, the incision is tightly closed with 




qi***** 









/—- ****-«£. «k-" 



VuLva 

Fig. 12 

Lymphatic drainage of Female Genitals. (Frequently asked) 



60 IMPORTANCE OF LYMPHATICS. 

sutures. Chronic inflammatory conditions have been found to 
do well under this form of treatment, it having been used many 
times for tuberculous bone disease. 

Chronic Lymphadenitis occurs typically in the course of 
three general diseases, — tuberculosis, syphilis and pseudoleuke- 
mia. In the first the glands are often removed ; although this 
may be followed by general infection. In the second, they 
are treated constitutionally and sometimes locally by mer- 
curials. In the third, they are, unless seriously threatening to 
life or function, left alone. 

A most admirable series of diagrams showing the relation 
of the lymphatics and their nodes to surgical procedures are 
given on page 428 et. seq. of "Park's Surgery." Eisendrath 
also devotes much attention to the subject. 

These studies of lymphatic drainage have been the deter- 
mining factors in establishing the present technic of all im- 
portant operations for the removal of carcinomata. This form 
of malignant growth is believed to spread entirely along the 
lymphatic channels, the characteristic enlargement of the lym- 
phatic nodes draining the involved tissues, affording perinent 
evidence of in support of this belief. 



CHAPTER VI. 
SHOCK. 

Crile has shown that the complicated condition known as 
surgical shock consists, when synthecized, of three secondary 
symptoms. These are loss of vasomotor control, disturbance 
of respiration, and interference with cardiac action. For the 
best and most recent presentation of the subject, reference is 
made to Brewer's text book, page 87, where the academic and 
clinical questions associated with it are fully discussed. 

It has been demonstrated that the great abdominal veins 
can hold all the blood there is in the body. A man, therefore, 
under certain conditions may bleed to death into his own ab- 
dominal veins. One of the most frequently discussed subjects 
in connection with shock is the question of establishing a differ- 
ential diagnosis between it and abdominal hemorrhage. Xow 
truly he who thinks to accurately establish such a diagnosis is 
wise beyond his years, no matter what his age. Why? If a 
patient suffering from shock has bled into his abdominal veins, 
and another one along side of him has slipped a ligature off, 
say the deep epigastric artery, and has bled into the cavity 
surrounding the veins, what important difference could one 
expect to find between the two? That the differential diagno- 
sis is so difficult as in many cases to be impossible, is attested 
to by the fact that the most expert diagnosticians may be ex- 
pected to fail. 

Obviously, the need of making this differential diagnosis 
is found chiefly among those cases in which the traumata have 
been limited entirely to the abdomen, signs of hemorrhage 
elsewhere being easily recognized. 

Another factor which obviously increases the difficulty of 
establishing a differential, is that every case of hemorrhage 
has associated with it a certain amount of shock. In other 
words, every case which bleeds into its abdominal cavity, 



62 SHOCK DIFFERENTIALS. 

bleeds also into its partially paralyzed abdominal veins. It 
therefore becomes practically a question of degree. 

Perhaps the one distinguishing feature between hemorr- 
hage and shock, outside of the history, is the attitude of the 
patient. In shock, he is said, as a rule, to be apathetic, whereas 
in hemorrhage, there is often a tendency to excitement. The 
excited form of shock is not, however, uncommon. 

Efforts have been made to differentiate the two by a blood 
examination, but the results have not yet been positive. 

Because of the failure to differentiate shock from internal 
hemorrhage, many persons have been killed. Nature's method 
of controlling hemorrhage is to slow the heart until coagulation 
in the wound takes place. This is why strong men faint at 
the sight of blood. Nature means to slow that man's heart 
the moment he is cut. Evidently the thing to do is to leave 
cases of internal hemorrhage alone, unless abdominal or vaginal 
section can be done. The treatment of shock is, on the other 
hand, to stimulate the heart. If therefore, shock be mistaken 
for hemorrhage, the patient is promptly killed by having the 
heart stimulated so that it pumps what little blood he has left 
out through the torn artery. 

A differential which is not rare is between fat embolism 
and. shock. This dreaded sequel of injury to the long bones 
is much more frequent than is usually supposed, a great many 
cases of shock being mistaken for it. Acute suppression of 
urine and pulmonary oedema have also to be differentiated 
from shock. 

Treatment. Surgical shock as before noted is almost al- 
ways associated with more or less hemorrhage. The patient 
is cold, pale and apathetic. The abdomen is not the only site 
where the body fluids have collected. They are also stagnating 
in the extremities. The brain is relatively dry. The indica- 
tions for treatment are cardiac stimulation, — external heat — 
this should be applied as vigorously as possible. Posture, — 
pour blood into the head by elevating the patient's feet. En- 
teroclysis, — this consists in turning the patient as nearly upside 
down as possible, and, in the absence of the customary layout, 
of inserting a large funnel as far into the rectum as possible. 
Through this funnel is poured a couple of litres of water at 



TREATMENT OF SHOCK. 63; 

a temperature of 49C (120 F.) Add two heaping teaspoonfuls 
of XaCl. In osmosis, when the fluid is absorbed, the lighter 
fluid passes much more rapidly through the membrane than 
the denser. Fresh water should therefore be absorbed from 
the rectum more rapidly than salt solution. It is, however,, 
more irritating to the mucous membrane and is therefore rarely 
used. The position in which the patient is held enables the- 
fluid to run down as far as and across the transverse colon. 
It is worth remembering that in the treatment of shock, as in 
that of threatened death from anesthesia, one of the first things 
to be done is to turn the patient upside down. Gravity will do 
a great deal to overcome cerebral anemia, as is well shown by 
the recovery of an over-chloroformed mouse when hung up by 
the tail. 

Infusion is another means of introducing fluid into the 
system. The execution of this technic requires a suitable 
canula connected with a cistern, and a certain amount of exper- 
ience is necessary to carry it out effectively and speedily. In 
this case, unlike that of the rectum, it is absolutely necessary 
that the salt solution should be prepared so as to be of practi- 
cally the same specific gravity as the blood. Otherwise, many 
corpuscles will be crenated and much damage will be done to 
the oxygen carrying power of the blood. Air must not be ad- 
mitted for air bubbles are as dangerous as fat globules. 

Hypodermoclysis is another method of introducing water 
into the body. It consists simply in connecting a large hol- 
low needle with a douche bag, the bag is filled with salt so~ 
lution at 120 ° and the needle is plunged into a region of soft 
cellular tissue, either beneath the breast or in the yielding 
regions of the back. Kemp has obtained important results in 
applying this method to conditions of diminished or suppressed 
urine. Either of the preceding methods will introduce fluid 
more rapidly than this one. Fifty or more cubic centimeters 
of salt solution, however, injected by hypodermoclysis over the 
region of the kidney will, in chosen cases, produce four or five 
times the amount of urine in an astonishingly short time. 

Elastic compression of extremities is an expedient which 
has been used for shock, notable by Dawbarn. A strong elas- 
tic band is placed about the extremity near the body, after 



<34 TREATMENT OF SHOCK. 

most of the blood has been forced out of it either by compres- 
sion or by posture. After say ten minutes, during which time 
the extremity has been deprived of its normal circulation, the 
blood is allowed to flow into it and another extremity is treated 
in the same way. 

What might be called the inverse of this plan has been 
vised for the treatment of coal gas poisoning. By tightening 
the elastic enough to stop the return circulation, the extremity 
is allowed to fill as full as the heart will pump it. By this 
means a considerable percentage of the poisoned body fluids 
are shut up in the extremity for a short time, during which 
the lungs and other purifying agents of the system have a 
better chance to get rid of the poisonous products than if they 
w r ere dealing with the entire mass. So the extremities may 
be used as reservoirs of the body fluids, to be emptied and filled 
at will. 

Immediate Operation. Relief from shock can generally 
be obtained by following the palliative treatment outlined. In 
cases of very severe injury, however, radical treatment may 
become necessary. As in the case of tetanus, it is imperative 
to thoroughly remove the focus of infection as well as to treat 
the symptoms. So in shock, it is important under certain con- 
ditions to remove the cause. There are two ways of doing 
this. First, the mutilated tissues may be amputated. This 
exchanges for a multiple set of nerve wounds, single wounds 
which naturally do not send as many complaints to headquar- 
ters as in the case of the primary multiple injury. Second, the 
mutilated nerves may be cocainized. This is best done by in- 
jecting 3 or 4 per cent, solution at the site of the injury, or a 
much weaker solution into the torn nerves, proximal to the 
wound. 

An application of the principle of the elastic bandage as 
used on the extremities, is well seen in the use of Crile's pneu- 
matic rubber suit. It resembles a diver's costume, being so 
arranged that, by inflating it, increased atmospheric pressure 
can be brought to bear upon the entire surface of the body ex- 
cept the head, and the field of operation. It is designed to force 
the blood from the surface and from the extremities into the 
starved cerebral circulation, and because more extensive should 
be more efficacious than the bandage. 

Of all drugs indicated in the treatment of shock undoubted- 
ly the most valuable is the remarkable non-toxic vaso-motor 
stimulant adrenalin. 



CHAPTER VII. 
SEPSIS; ACUTE. 




Fig. VS 

This is adapted from Eisendrath's Clinical Anatomy. It shows 
very clearly how sepsis may travel by continuity from the 
face to the Internal Jugular and by contiguity to the Brain 
and its Membranes. 

(By courtesy of Db. Eisendrath)' 

Brewer, page 41 of text book, presents this subject more 
tersely and intelligibly than any one else. He says : 

"Septicemia, Pyemia and Septic Intoxication, — although 
formerly considered separate diseases, these three conditions 
are best regarded simply as different types of acute general 
sepsis. AVhenever pathogenic bacteria gain access to and grow 
in, the systemic circulation and tissues, the condition is re- 
ferred to as septicemia. If, on the other hand, such general- 
ized infection be associated with the development of foci of 
suppuration,, it is designated pyemia. The term septic intoxica- 
tion is used to indicate a condition due to the absorption of 



66 TEMPERATURE TABLE. 

toxins mainly of bacterial origin. Sapremia is a term some- 
times employed to signify a form of intoxication dne to absorp- 
tion of the poisons of putrefactive micro-organisms. It is not 
always possible to distinguish sharply between infections and 
intoxications, indeed, the manifestations of infectious disease 
are nearly always referable to bacterial poisons." 

One of the first things suggested by a consideration of 
sepsis is temperature. 

The following table of temperatures, with all the failings 
of an emperic classification, has points of merit. 

Given a patient convalescent from some such simple opera- 
tion as an interval appendectomy. 

(i) One to twelve hours after operation, temperature 101. 
This is post-operative reaction, and has been ascribed to dis- 
turbance of the thermo-genetic centers. 

(2) Twelve to twenty-four hours after operation, tem- 
perature 101. What is it? 

Probably what is known as surgical fever or aseptic wound 
fever. This is uncommon if there has been heavy hemorrhage. 
It is also unlikely to occur if no blood has accumulated in the 
wound after operation. It is due to the absorption of blood 
clot, ligatures, and possibly antiseptic solutions. 

(3) Twenty-four to thirty-six hours after operation, tem- 
perature 102. This is auto-intoxication from the bowels and 
is remedied by a purge. 

(4) Thirty-six to seventy-two hours after operation, tem- 
perature 101 and rising. This is the real thing, for this inter- 
val represents the average period of development required by 
the pyogenic germs. 

(5) After seventy-two hours, out of the woods. 
Treatment of all nurse, feed and stimulate. In addition, 

for (2), dry wounds; for (3), catharsis. Wash rectum and 
colon. For (4), drainage, antiseptics, antitoxin-sera, infu- 
sions, Crede's ointment. 

Recovery has been known to take place between the ex- 
treme temperatures of 75. 2° and 114.8 F. (Br. Med. Jour. Feb. 
7> '04). 






67 



DIFFERENTIAL BETWEEN 



Tetanus. 



Strychnine. 



Hydrophobia. 



Lyssophobia. 
(lyssa-rage) 



Punctured wound. 



Incubation 3 to 7 



History oe Injury. 
Overdose. | Bite. 



days. 



Babies and adults 



Negro. 



Immediate. 



Adults. 



Negative. 



Disease. 

! Ten weeks. 



Ace. 



Increases as Equa- 1 
tor is approach- J Negative. 
ed. 



Children and 
adults. 



Race. 

Negative. 

Climate. 

Central Europe. 



Sore throat. Later 
may be agoniz- 
ing. 



Stiffness of cervi- 
cal and maxil- 
lary muscles. 
Inability to 
open mouth. 



Not constant. 



Pain. 

j 
Often in back. j In wound. 

Disability. 

Defective speech 
Jaws not rigid at and inspiration, 
first. Deglutition 

spasms. 

i 

Vomiting. 
Frequent. j Absent. 

! 

Bowels. 

i 



Bite. 



Irregular: typical- 
ly within a week 



Adolesence. 



Latin Races. 



Southern Europe. 



Marked mental. 



May imitate any 
or all symptoms 
of others. 



Often present. 



Irregular. J May be diarrhea i Negative. j Constipated 



68 



DIFFERENTIAL BETWEEN.— Continued 



Tetanus. 



Strychnine. 



Hydrophobia. 



Lyssophobia. 
(lyssa-rage) 



99 to 100. 



98 to 100, except 
| after a spasm. 



Temperature. 

99.5 to 102.5 



98. 6 or sub - nor- 
mal. 



Respiration. 



Dyspnea during D ysp n e a, not 
paroxysme. marked. 



Respiratory 
spasms. 



Irregularly parox- 
Ysmal. 



Mind clear. 



Neryous Symptoms. (Central) 
Clear. 



Melancholia. De- Hysterical mani- 
lirium common. festations. 



Paresthesiae. 



Peripheral 
Green vision and 



retinal hyperes- 
thesia. 



^ r s1Iot 0nOT ! ParaStheSiae - 



GENERAL PHYSICAL. 

Facies. 



Sardonic grin. Anxious. 



Anxious and; 



drawn. 



Excited, anxious. 



Nutrition. 



Negative. 



[Negative. 



Mav be diminish- 
ed. 



Tvpically deprav 
ed. 



REFLEXES. 



Clonic exacerba- 



tions converting- _ . , .... 

spastic ri^iditvi Ton,c exacerbatl s 
into violent and wit f h inte ™ ls of Increased. 

i . rest. 

convulsive mus 

cular activity. 



Diminished or in- 
creased. 



LOCAL PHYSICAL. 



In nearly one-half 
wound is on 
foot or hand. 



No wound. 



Bi face freqUent \ Bite aQ y where - 



69 



DIFFERENTIAL BETWEEN.— Continued. 



Tetanus. 



Strychnine. 



Hydrophobia. 



Lyssophobia. 
(lyssa-rage) 



11,000. 



Probably fatal. 



Neighborhood of 
wound filled 
with bacilli. 



LABORATORY FINDINGS. 

Blood. 
Leucocyte Count. 

Negative. j Negative. Normal. 

i 
Injection. 

! I 

Negative. j Probably fatal. j Negative 

i I 

Tissue Section. 

Negative. 



Acute hyperemia 
of wound tissue 



Wound tissue nor- 
mal. 



There are other diseases or groups of symptoms which 
may be differentiated from these four. One frequently con- 
founded with tetanus is Tetany. It resembles tetanus only in 
name and in the fact that occasionally the same muscle groups 
are attached with spasms. It may have a nervous or an auto- 
intoxicational origin. It is uncommon in this country and has 
a zero mortality rate. 



SEPSIS; CHRONIC. 

As already stated, Brewer's classification of the infectious 
surgical diseases presents them in a very simple and easily 
understood form. The chronic infections which have a surgi- 
cal bearing, are tuberculosis, syphilis, and actionomycosis. 

Tuberculosis, otherwise known as the White Man's 
Plague, kills one out of seven. By far the greater number of 
these deaths are caused by infection of the lungs or brain. 
These are as yet practically beyond surgical intervention. 
There is, however, no known part of the body which the tuber- 
cle germ has not invaded. 

In the chapter on inflammation, the onion like formation 
of the typical tubercle was discussed, it being noted that the 



70 SURGICAL TREATMENT OF TUBERCULOSIS. 

irritation produced by the establishment of the tubercle germ 
in the tissues resembled in miniature, and in a way easily 
studied, the more vigorous and destructive action of other 
germs. The onion like series of hollow spheres enveloping the 
part were particularly noted. It was not stated, however, that 
the work of the fibroblasts in the case of a tubercle does not 
end with the mere formation of scar tissue. In tuberculosis 
Nature goes a step further in the protection of the organism, 
by causing calcification of the scar tissue. When patients are 
sent to the mountains, the air furthers scar formation and 
calcification more rapidly than it does in the lowlands and 
particularly in the cities. After perhaps a year's sojourn in 
the hills, the patient is allowed to return. Often within a few 
days, supposing the infection to have been pulmonary, he 
begins to cough and to expectorate. What has happened? 
Lowland air is not as friendly to the newly developed scar tis- 
sue as air of the uplands. Some has broken down and has 
allowed the impounded germs to escape. In other words, 
calcification of these little areas has not been allowed to com- 
plete itself and the patient's life has been placed in jeopardy 
by bringing him home too soon. 

Tuberculosis then is cured by Nature's process of walling 
the germ oft" within a limestone shell. These little shells be- 
come incysted in the tissues and remain there as harmless 
foreign bodies throughout life. It is also sometimes cured by 
spontaneous extrusion of the germs. 

What is man's method of curing tuberculosis? Simply 
a following of Nature. We may help her to incyst or to 
extrude. The Radical method or treatment by open incision 
has very distinct limitations. The conservative method, or 
treatment by rest and extension has a much wider field. The 
first is practised by the general surgeon, the second by the 
orthopedic surgeon. 

What determines the falling of a given case of surgical 
tuberculosis into the hands of one class or the other? Just 
one condition, and that one alone. If the infection be a pure 
one, that is to say if there are no pyogenic germs in conjunc- 
tion with the tubercular germs the man of plaster, pulleys and 
weights should have the say. If, however, pyogenic germs be 



HIP-JOINT TUBERCULOSIS. 71 

present, the man with the knife cannot too quickly aid Nature 
in her effort to cast them out of the body. 

For it is to be noted that the "walling off" method is not 
Nature's only means of curing tuberculosis. Under certain 
conditions she agrees to let them stay within the organism, 
making them harmless by putting a stone wall around them, 
but under other conditions, she breaks open the skin and 
crowds the offenders out. This accounts for the existence of 
these two distinct classes of surgeons. They each do their 
w r ork in accordance with one of Nature's methods, simply 
giving a hand to help her out. 

What is the etiology of the average case of surgical tuber- 
culosis? It may be said in general that tuberculous lesions 
arise from moderate acute injuries, once inflicted, whereas 
malignant lesions arise from infinitely slight injuries many 
times inflicted. 

A little child falls from its crib to the floor, cries with pain, 
puts his hand on his hip, and in six weeks has the early char- 
acteristic symptoms of coxitis. An old Irishman with broken 
tooth or rough T. D., — year in and year out wounds and irri- 
tates his lip until the epithelioma grows. 

PURE CULTURE, SURGICAL TUBERCULOSIS. 

A consideration of this immense field is outside the scope 
of this book. Pure culture tuberculosis gives bread and butter 
to the orthopedic surgeon. Some of the most interesting 
lesions of this class are : 

Coxitis. This is also known as hip joint disease. Its etiol- 
ogy has been given. The great majority of the cases can be 
traced to minor injuries which were neglected. The pathology 
is that of wet productive inflammation which later on becomes 
practically dry. This is of course supposing the case to remain 
free from mixed infection. The tubercle, if it produces pus at 
all, does so in such very small quantities that the system may 
be said to be always able to carry it away and never under the 
necessity of extruding it through the skin. This happens 
typically only when mixed infection occurs. 

The symptoms are perhaps more in^ortant than those of 



72 KNEE-JOINT TUBERCULOSIS. 

any other chronic disease, for the utility or perhaps the life 
of the individual depends upon their early recognition. 

If a recent preparation is made in the dissecting room, with 
ligaments in place but everything else removed, the pelvis being 
sawed in two through the median line antero posteriorly and 
the femur cut at about its middle, a demonstration can be made 
which probably explains the position assumed in the first stage 
of hip disease. The extremity is abducted and externally ro- 
tated. Students often get the idea that the first stage is internal 
rotation and adduction. It is not. It is, however, too often the 
first stage in the eyes of the general practitionei, to the eternal 
misfortune of the child. 

Take the preparation above alluded to and bore a hole 
through the ilium opposite the head of the femur. Screw in 
a hollow tap and connect it Avith a water pump. Hold the 
preparation up and the femur assumes a position governed by 
gravity. Force in water, and the bone, as though it were 
alive, will slowly but surely rotate externally and abduct itself 
from the mid-line. So closely does this experiment simulate 
the process which must take place in nature, that it affords 
incontrovertible evidence that the parts assume the position 
of external rotation and abduction in the first stages simply 
because the joint is full of water. By rotating the head of the 
femur in that direction the joint cavity will hold more water 
than in any other position of the bone. 

The second position of the extremity is characteristic. It 
is the result ; the direct result as was the first, of the inflamma- 
tory process. An understanding of this process should prevent 
any one from making any mistake about it. It is caused by 
contractures due to the normal and usual process of productive 
inflammation. There is no better example in the whole of 
medicine than coxitis, of how easy it is to predict the symptoms 
of a case by simply working them out on the basis of inflamma- 
tion. It is footless to memorize these symptoms. Know what 
to expect from a thorough acquaintance with the inflammatory 
process and there isn't a disease, the bulk of whose symptoms 
you cannot accurately predict without ever having seen a case 
or read a word on the subject. 

A third stage is sometimes described. Like the big 



EPIPHYSITIS. 73 

fibroids weighing forty pounds, it is rarely seen in these days. 
You are in luck if the gynecologists ever let you see a fibroid 
weighing ten pounds, let alone forty, and you cannot, except 
in most densely ignorant communities, expect to see a child in 
the pitiable advanced third stage of coxitis. 




Fig. 14 

Acute femoral epiphysitis in child eight years old. Lesion ap- 
pears as white oval in the epiphysis. Note patella and fibula, 
also the wide separation of epiphysis from diaphysis. 

The adduction and internal rotation has gone on and com- 
bined with such a degree of flexion that deep sores may be 
made on the well leg by pressure of the contractured sick side. 
The patient has been unable to walk for months and perhaps 
for years. 

The differential diagnosis of the many forms of hip disease 
is of the gravest importance. 



74 



DIFFERENTIAL IN CHILD BETWEEN 



Tuberculous 
Coxitis. 



Syphilitic 
Coxitis. 



Coxa-Vara. 



Rheumatism. 



History ok Injury. 



Slight, single, 
acute. 



Onset insidious. 



Absent. 



May be present. 



History ok Disease. 



Usually in parent. 
May' rarely be 
acquired. Onset 
slow. 



Nutritional d i s ■ 
turbances. On- 
set very slow. 



Absent. 



In other joints. 
Onset acute. 



Previous Disease. 



Occasionally i n 
lungs or else- 
where. 


Negative. 




Evidences of ra- 
chitis. 


Tonsilitis, con 
j unctivitis 
rheumatic dia 
thesis. 




Pain. 




lf i j Marked, 
Marked, night. 


worse at 


Slight or absent. 


Marked. 




Disability. 




Marked. 


Marked. 




Variable. 


Very marked. 




Temperature. 




100 to 102. 


99 to 101. 




Normal. 


102 to 104. 




Pulse. 




110. 


no. 




80 to 90. 


120. 




Respiration. 




22 to 26. 


22 to 26. 




20. 


26 to 30. 


NERVOUS SYMPTOMS. 






Central. 




Negative, unless 
meningitis com- 
plicating. 


Negative. 




Negative. 


May be delirium. 



75 



DIFFERENTIAL IN CHILD BETWEEN.— Continued. 



Tuberculous 
Coxitis. 



Syphilitic 
Coxitis. 



Coxa- Vara. 



Rheumatism. 



GENERAL PHYSICAL. 
Facies. 



Drawn. 



Normal or slightly 
below. 



Absent, if primary 



First stage, ab- 
duction, exter- 
nal rotation. 
Apparent leng- 
thening. 



Old man. 



Always bad. 



General, discreet 
involvement. 



Square face of ra- 
chitis. 



Nuteition. 

May be fat. 
Glands. 

Absent. 



Evidence of 



Negative. 



Absent. 



pain. 



LOCAL PHYSICAL. 

Inspection. 



Same as T. B. in 
early stage. 



Variable, but of- 
Eversion, appar-' teri abducted 



ent shortening. 



Palpation. 



Adduction and in- 
ternal rotation 'Same as T. B. 
painful. 



Extreme abduc- 
tion impossible, 
but not painful. 



and externally 
rotated. 



A 1 1 movements 
painful, but par- 
ticularly adduc- 
tion and inter- 
nal rotation. 



Mensuration. 



Trochanter in nor- 
mal position. 



Tuberculin. 



Same as T. B. 



Trochanter often 
above Neleton's 
line. 



Effect of Drugs. 
Mixed treatment. Negative. 



Normal. 



Salicylates. 



The knee is a favorite site for pure culture tuberculous in- 
fection. The T. B. germ has a predilection for new rapidly 
growing parts, presumably because the\ r are tender. The 



76 



PURE CULTURE TUBERCULOSIS. 



epiphysis is consequently a favorite site. The accompanying 
figure of a radiogram of epiphysitis of the knee of a child not 
alone shows the lesion of epiphysitis very beautifully, but also 
demonstrates what a large and tangible structure the epiphysis 
is. It is often erroneously thought of as a line, but it is in fact 
a good sized solid body throughout childhood. Reference is 
suggested to Brewer's text book, page 520, where a diagram is 
shown giving the time of bony union of the epiphyseal junc- 
tions. On the good old principle that the "Last shall be first 
and the first shall be last," the bones last formed are first to 
unite, the first formed the last to unite. 

Pure culture infection of the ankle is not infrequent. It 
has frequently to be differentiated from syphilis, rheumatism 
and flat foot. 

DIFFERENTIAL IN YOUNG ADULT BETWEEN 



Tuberculosis of 

Tibio-fibulo- 

tarsal or inter- 

Tarsal Joints. 



Syphilis of 
Same. 



Rheumatism of 
Same. 



Flat Foot. 



Moderate acute 
and neglected. 



May be secondary 
Onset slow. 



History of Injury. 

May or may not| A bsent 
be absent. I ADSent - 



History of Disease. 



Negative. 



Chancre. Onset 
slow. 



Diathetic signs. 
Onset rapid. 



Negative. 



Malformation. 



Negative. 



Often present, ei" 
ther acute or 
chronic. 



Often during con" 
valesence from 
wasting disease 



Often short tendo> 
Achilles. 



None. 



Severe, constant. 



None. 



Previous Injury. 
None. 



Severe, worse at 
night. 



Pain. 

Very acute. 



Often follows bad- 
ly set Pott's 
Fracture. 



Only on bearing 
weight of body. 



DIFFERENTIAL IN YOUNG ADULT BETWEEN.— Continued. 



Tuberculosis of 

Tibio-fibulo- 

tarsal or inter- 

Tarsal Joints. 



Syphilis of 
Same. 



Rheumatism of 
Same. 



Flat Foot 



Marked. 



Disability. 



Marked. 



Complete. 



Variable, but al- 
ways present to 
some degree. 



LOCAL PHYSICAL. 

Inspection. 



Drop foot. Swell- 
ing not red, ta- 
pering, (if old). 



Drop foot, dark 
red, localized 
swelling. 



Drop foot, scarlet, 
localized swell- 
ing. 



Palpation. 



Negative, save for 
diffuse tender- 
ness and pain 
over most mark- 
ed area of infec- 
tion. 



Same. 



Diffuse tender- 
ness. Pain over 
joint line. 



Drug Administration. 



Tuberculin 
tion. 



Improvement. 



Mixed treatment. 



Salicylate. 



Mechanical Treatment 



Improvement. 



No improvement. 



Loss of arch, pro- 
minence of peri- 
neal tendons 
and scaphoid. 



Absolutely char- 
acteristic points 
of tenderness: 
(1) Internal mal- 
leolus; (2) Inter- 
nal calcaneo- 
navicular Hga- 
ment; (3) Over 
center of sole 
due to stretch- 
ing of plantar 
ligament; (4) 
Dorsal junction 
of a astragalus 
and navicular ; 
(5) External 
malleolus. 



Negative. 



Stretch tendon' if 

necessary. 
Arch curative. 



The treatment of all these pure culture forms of infection 
if they attack the joints as they usually do, is summed up in 
few words, — Essence of time and tincture of patience. 



7s 



PURE CULTURE TUBERCULOSIS. 



Immobolize ; extend, and unless the infection becomes 
mixed, you should have a cure in a large per cent of cases, in 
about the same time as it took the patient to get sick. 

Pure culture surgical tuberculosis is also seen very fre- 
quently in the bodies of the vertebrae. The inflammatory re- 
actions produced in this case are grouped together under a set 
of symptoms generally known as Pott's Disease. Like all 
other pure T. B. infections it is absolutely essential that it be 
recognized early to insure protection of the parts from injury. 
Neglect is the most potent cause of mixed infection. Its early 
differential diagnosis is therefore paramount. 

DIFFERENTIAL BETWEEN 



Spondylitis. 
(Potts Disease)' 



' Scoliosis. 
(Curvature) 



Hysterical 

Spine. 



Spinal Sprain. 



May be slight 
knuckle. 



Frequent, but not 
invariable. 



Evidence of germ 
infection. Onset 
slow. 



Possible. 



• History of Tumoe. 

May be tumefac-l 
tion, but more Absent, 
diffuse. 



Injury. 
Possible, but rare 



Present or absent, 
according to 
whim of patient 



Disease. 



Negative. Onset 
very slow. 



Onset often acute 



Absent. 



Severe, always 
present. 



Onset always im- 
mediate. 



Previous Injury. 



Carrying loads on 
one side or sit- 
ting in badly 
built school 
chair. 



Frequently the 
suggesting 
agent. 



Negative. 



Previous Disease. 



Possibly second- 
ary. T. B. else- 
where. 



Frequently h i s - 
t or y of ante- 
rior polyo-mye- 
litis but rarely 
recognized as 
such. 



Frequently chlo- 

rosis^and uterine 1 Negative, 
disorder. 



79- 



DIFFERENTIAL BETWEEN.— Continued. 



Spondylitis. 
(Pott's Disease) 



Scoliosis. 
(Curvature) 



Hysterical 
Spine. 



Spinal Sprain. 



Children. 



Negative. 



Adolesence. 



(Female. 



Age. 

Young adult. 
Sex. 

Female. 



Pain. 



Marked on mov- 
ing. Belly-ache L u h lf 
wakes from y s 3 

sleep. 



Constant, but does 
not waken 
from sleep. 



Disability. 



To jump, abso- 
lute ; to walk in 
upright posi- 
tion, increasing. 
Grunting respi- 
ration. 



Evening rise, 99 to 
101. 



Weakness, no pos- 
itive disability. 



Depends on abili- 
ty of patient to 
simulate Pott's. 



Temperature. 



Normal. 



Often 96 to 98. 



Adult. 



Male. 



Severe, especially 
during certain 
movements. 



Often limited to 
doing the exer- 
cise which caus- 
ed it, for exam- 
ple, lifting. 



Normal. 



Paresthesiae. 



Pain referred to 
parts enervated 
by nerve escap- 
ing near lesion. 
Bi-lateral. Cen- 
tral origin. 



If present, often 
due to pressure 
of rib on inter- 
costal nerve. 
Frequently uni- 
lateral. Peri- 
pheral. 



Not referred. Lo- 
cated just one 
side or the other 
of the spines, 
usually at one or 
other of the typ- 
ical hysterica] 
points. 



Localized over- 
site of ligamen- 
tous rupture. 



Knee-jerk may be 
exaggerated. 



GENERAL PHYSICAL. 
Reflexes. 



Negative. 



Absent, normal or 
exaggerated. 



Negative. 



80 



DIFFERENTIAL BETWEEN.— Continued. 



Spondylitis. 
(Pott's Diskase) 



Scoliosis. 
(Curvature) 



Hysterical 

Spine. 



Spinal Sprain. 



LOCAL PHYSICAL. 



Inspection. 



■Single, sharp 
knuckle may be 
present. 



If kyphotic in 
type (rare), it 
may closely sim- 
ulate-Pott's. 



May seem to be a 
prominence of 
several spines 
(owing to usual 
extreme thin- 
n e s-s of patient 
and to the 
fact that they 
droop the shoul- 
ders, which 
partly obliter- 
ates the normal 
lumbar lordosis) 



Negative. 



Palpation. 



No tenderness on 
pressure. 



Same. 



Marked tender- 
ness. 



Tenderness over 
traumatism. 



Effect of Extension and Immobilization. 



Marked improve- 
ment within a 
week. 



Continued and 
progressive dis- 
abilitv. 



No improvement. 



Immediate relief. 



It can readily be seen that a differential between Pott's 
and scoliosis of the kyphotic type is by no means easy. It is 
nevertheless of very great importance, for in order to obtain 
the best results the one should be put at absolute rest in exten- 
sion, while the other should be pulled and hauled and mauled 
and exercised up to the very last limit of the patient's en- 
durance. 



81 



MIXED CULTURE TUBERCULOUS INFECTIONS. 



These should rightly fall under the care of the general 
surgeon as they usually call for immediate radical treatment. 
Some of the more frequent differentials of this group in the 
knee region are as follows: 



Acute 
osteomyelit 



Acute 
Epiphysitis 



Rheumatism. 



Septic 
Arthritis. 



If present, noti^ ,, 

marked. Often {Frequently pres 



absent. 



Within 33 to 72 
hours. 



May be pyemia. 
Typhoid, etc. 



Child. 



Very severe. Bet- 
ter if tumor ap- 
pears. 



Not present in 
joint. 



Usual. 



ent. 



History of Tumor. 
Present. 



Injury. 
Absent. 
Previous Disease. 



Present, may be 
marked. 



33 to 72 hours. 



Same 



Child. 



Severe. 



Diathesis. 
Age. 

Child or youth. Any age 

Pain. 



Pneumonia or the 
like. 



Same. 
Disability. 



Slight in joint 



Same. 



Marked in joint. 
Vomiting. 

Occasional. 



Same. 



Same. 



Very frequent. 



NERVOUS SYMPTOMS. 

Delirium. 



Early 



Present if severe. Early, 



82 



DIFFERENTIAL BETWEEN.— Continued. 



Acute 
Osteomyelitis. 



Acute 
Epiphysitis. 




Septic- 
Arthritis. 



White or light red. 
Slight swelling 
usual. Absent 
if periostiumnot 
involved. On 
diaphysis. 



LOCAL PHYSICAL. 



Inspection. 



Red. Swelling 
constant and 
early ; in neigh- 
borhood of joint 
Localized either 
above or below 
it, unless sec- 
ondary joint ef- 
fusion present. 



Crimson. General 
swelling of joint! 
very marked. ' 
Joint outline 
gone. 



Dusky red. Swell- 
ing marked. 
Outline of joint 
obliterated. 



Exploratory Incision 



Pus often not 
reached except 
by bone section. 
May be only a 
drop. 



Pus apt to be 
nearer surface. 



No pus. Often 
much fluid. May 
show charac- 
teristic germ 



Quantities of pus 
free in joint. 



CHAPTER VIII. 

SYPHILIS AND GONORRHEA. 

Syphilis is one of the most interesting of all diseases. We 
are all more or less profoundly infected with it. If we were 
not, primary syphilis would kill thousands upon thousands of 
people, whereas it is known to have practically a zero mortality. 
There is a large stock of good lively racial antitoxin on hand 
which is the product of our ancestors' struggles for life against 
this invasion. This antitoxin, like other individual characteris- 
tics, is handed on to the child through the agency of the ovum 
and the spermatozoon. As in the case of other characteristics 
transmitted through these agents, the inherent resistance of 
individuals to syphilitic infection varies profoundly. Some ap- 
pear to be as immune as goats, whereas others have been 
granted but little immunity. 

It is only 300 years ago since primary syphilis killed count- 
less thousands of Europeans. Historically the course of this dis- 
ease is marvellously interesting ; suffice it, however, to say that 
during the restless period of European development, when Na- 
ples was infested by the armies of France and of Spain, the dis- 
ease was so rife among the soldiers and killed such numbers of 
them that the French called it the Italian disease, the Italians 
called it the French disease, and the Spaniards were at liberty 
to choose between the two. Any one who is further interest- 
ed in this remarkable scourge will find a fascinating account 
of it and its ravages, as well as the attempts which been 
made to control it, in that masterpiece, Sanger's "History of 
Prostitution.'' 

Due to some infectious agent, the character of which is un- 
known, this disease, in an individual to whom has been granted 
the usual amount of racial resistance, pursues a course which, 
for constancy of symptoms on the one hand, and for mimicry 
on the other, far excels and surpasses any known disorder. 
What the actual cause mav be for the fact that certain indi- 



84 



INFLAMMATORY MANIFESTATIONS OF SYPHILIS. 



viduals are endowed with a greater resisting power than others, 
is, of course, conjectural, but if protection in syphilis arises, as 
history seems to show it to do, by ancestor infection, it is prob- 
able that these fortunate individuals had incestors of question- 
able morals. Thus arises the possible ethical question as to 
what our attitude should be toward establishing protection for 
posterity. 




sJ*- 



*r" 









Fig. 15 

Scheme for drawing the articulations of the wrist. This composit 
joint is occasionally invaded by syphilis. 

The syphilitic inflammatory process, whatever its activity, 
or whatever its virulence, has one constant factor. It begins on 
the surface of the body and marches relentlessly, slowly, but as 
surely to the center. It may take twenty years to make this 
short journey, but unless retarded by incessant treatment, make 
it, it will. This conception of the disease is a convenient way 
of interpreting or of predicting the symptoms of the three 
classical stages which are familiar to all. Like every other 
lesion, its course must be studied from the standpoint of in- 
flammatory reaction. In its long career it gives manifestation 
of every possible phase of inflammation. More properly speak- 
ing, it affords excellent proof that the classification of inflam- 
matory reactions which has been developed to facilitate its 
study, is simply an arbitrary division into several classes all 



LAWS GOVERNING SYPHILITIC INFECTION. 85 

part and parcel of one process. They are too apt to be looked 
upon as having separate entities with distinct modes of devel- 
opment. 

Syphilis is the most perfect mimic of all diseases. It might 
aptly be called the Pathological Clown. So many times has it 
deceived the most astute diagnosticians that one of them pro- 
pounded the well known wary phrase : "When in Doubt 
Give K. I." From headache on the one hand to toe ulcer on 
the other, there is not a condition for which this remarkably 
versatile disorder may not be mistaken. For this reason the 
number of differentials between syphilis and its likenesses is 
simply innumerable. A number have already been touched 
upon. Conclusion is often impossible except by aid of treat- 
ment, which in time reveals the true nature of the case. 

No less certain than the classic course of symptoms in this 
disease is the degree of probability of its occurrence in certain 
definite cases. These have been carefully studied and have 
been grouped according to certain laws. 

Colle's Immunity. — This law refers to the mother. 
It signifies that immunity which exists in healthy mothers 
who, owing to the presence of syphilis in the father, have had 
syphilitic offspring. The mothers escape all clinical evidence 
of syphilis. 

Profeta's Immunity. — This refers to the child. It 
is the immunity which exists in the children of syphilitic 
parents. In many such cases, the father or mother, one or 
both, being syphilitic, the children nevertheless remain healthy. 
Any explanation of these extraordinary facts must, in the 
light of our present ignorance of the nature of the syphilitic 
infection, be purely hypothetical. The most probable belief is 
that the child of syphilitic parents is infected with the anti- 
bodies (racial) in excess of the pro-bodies (parental). In addi- 
tion to the racial anti-bodies, the child creates individual anti- 
bodies by the usual method of reciprocal production. By this 
overdose he is spared the clinical manifestations of syphilis and 
grows to healthy adult life. 



86 



DIFFERENTIAL BETWEEN 



Labial Chancre 



Epithelioma. 



Chancroid. 



Herpes. 



Slight elevation. Same. 



Absent. 



Signs of systemic 
infection. Incu- 
bation 10 days 
to 3 weeks. 



History of Tumor. 
Absent. 
Injury. 

Absent. 



Moderate, chronic 
and multiple. 



History of Disease. 



No incubation. 
Onset very slow. 



No incubation. 



Absent. 



Acute irritation. 



May complicate a 
neurosis, cold or 
fever. No incu- 
bation. 



Negative. 



Not possible. 



Young adult. 



Female. 



Always absent. 



Marked. 



to 101 



Almost invariably 
present. 



Previous Injury. 
Negative. 



Negative. 



Previous Disease. 



Same. 



More common af 
ter 40. 



Male, 2000% more 
frequent than 
female. 



Often severe 
(May be referr 
ed) 



Often elsewhere. May be elsewhere 
Age. 

Young adult. Any age. 

Sex. 

Negative. Negative. 

Pain. 

Typically present. Present. 
Disability. 



Not marked 



Normal. 



Marked. 
Temperature. 

100 to 102. 



Very marked. 



Normal. 



87 



DIFFERENTIAL BETWEEN.— Continued. 



Labial Chancre. Epithelioma. Chanc 



Hj 



GENERAL PHYSICAL. 
Geands. 



Early; discreet, 
epitrochlear first 
involved. 



Orny glands of lo- 
cal drainage. 
Late infection. 



Same, but early 
infection. 



No enlargement. 



LOCAL PHYSICAL. 



Single or simulta- 
neously multiple 
Round or sym- 
metrically ir- 
regular. Super- 
ficial. Either lip. 
Red glazed scab. 
Secretion scanty 
serous. 



Typically hard. 
Ends abruptly 
in normal skin. 



Single. 

Unsymmetrically 
irregular. 

Superficial. 

Lower lip. 

Fungous granula- 
tions. 

Hemorrhagic. 



Inspection. 

Often multiple. 

Unsymmetrically 
irregular. 

Punched out. 

Either lip. 

Worm eaten bot- 
. torn. 

Purulent, abun- 
dant. 



Palpation 

Solid, but not hard 
unless thickly 
crusted. 



Typically soft. 



Multiple and con- 
fluent. 
Irregular. 
Superficial. 
Either lip. 
Pultaceons. 
Moderate. 



Same as chancroid 



BLOOD. 

Differential Leucocyte. 



Lymphocytes, 40- 
50$. Polymor- 
phonuclear 45- Negative. 
60&. Hemoglo- 
bin 50-60%. 



May fall as low as 
.b7 (Cabot) 



Inflammatory evi- 
dence. 



Not indicated but 
Hg. will modify 



Negative. 



Typical pearl nest 
formation. 



Negative. 



Color Index. 

Negative. 
Tissue Section. 
Atypical. 



Drug Administration. 
No effect. X-Ray' 



heals. 



Antiseptics heal. 



Negative. 



Negative. 



Atypical. 



Antiseptics heal. 



88 GONORRHEAL PYEMIA. 

Syphilitic infections of the hard or soft parts, particularly 
in the late secondary and tertiary stages, offer pleasing ground 
for mixed infection. Hence it often becomes necessary to sub- 
ject them to radical surgical treatment. In this event one of 
the most useful differentials is between Gumma and Sar- 
coma. The chancre, which is the characteristic lesion of the 
primary stage, has often to be differentiated from epithelio- 
mata. This is a bit of side light which shows the relation of 
these four lesions to the surface and to the deeper structures 
of the body. 

Syphilis is the most frequent cause of Dry Productive In- 
flammation, The sclerosis of the kidneys and liver kill thou- 
sands of men and women. The same lesion invades the cord, 
causing 90 per cent, of cord diseases, while our asylums are 
overburdened with the victims of syphilitic brain sclerosis. 

Remotely, then, syphilis has a tremendous mortality rate. 

GONORRHEA. 

This second rate acute infectious disease has no right to 
be associated with a lesion so abstruse, so separate, and so dis- 
tinct from it as syphilis. It is one of the most typical acute 
septic infections. Probably the explanation for their having 
been placed cheek by jowl in most text books is to be found in 
the importance of the one point which they have in common, 
viz., the frequency of their venereal origin. The chief interest 
to be found in a study of gonorrhea lies in the occasional mani- 
festation of the pyemic capability of the germ. 

Especially under such favorable conditions as epididimo- 
orchitis, acute gonorrheal prostatitis, or cystitis, the germ occa- 
sionally wanders out in considerable numbers into the general 
circulation and becomes localized at some point of minimum 
resistance. Such a point is often a joint, and the knee joint is 
particularly prone to fall prey to it. This condition of localiza- 
tion of the cocus in or about the joints has been erroneously 
called Gonorrheal Rheumatism. There might be some excuse 
for it if it resembled in any way acute mono-articular rheuma- 
tism, which is undoubtedly of germ origin, but unhappily, it is 
anything but acute in its course. The moment, furthermore, 



GONORRHEAL ARTHRITIS. 



89 



that mono-articular rheumatism so called is proved to have 
a septic nature it ceases to have claim to the word "rheuma- 
tism." 

Gonorrheal Arthritis, then, is the name of the day. The 
treatment of this condition has in the past been most unsatis- 
factory. It is safe to say that no treatment whatsoever, save 
one, either local or constitutional, has any influence upon the 
course of the disease. Its tendency is toward recovery, but the 
processes of productive inflammation have so long been active 
that the joint is always more or less impaired because it is 
filled with scar tissue. 

The Modern Method of Treatment.— Rather than let a 
man walk around on crutches for two years during the most 
active part of his life, rather than subject him to the pain of all 
forms of counter-irritant local treatment, it is now deemed ad- 
visable to cut boldly across the joint as Mayo has recommended 
should be done in case of acute septic arthritis and prevent 
the productive inflammatory changes by washing away their 
creators. Copious irrigation and prolonged soaking in mildly 
antiseptic solutions are said on very good authority to be dis- 
tinctly curative of this condition. One of the possible lesions, 
with which gonorrheal arthritis may be confounded is pure 
culture tuberculous arthritis and another is chronic articular 
rheumatism. 



DIFFERENTIAL BETWEEN 



Gonorrheal 
Arthritis. 



Rheumatic 
Arthritis. 



Pure Tubercu- 
lous Arthritis. 



Loose Body in 
Joint. 



History of Tumor. 



Moderate, diffuse 
swelling. 



May be absent. 
Occasionally lo- 
calized. 



Apparent tumor 
due largely to 
wasting above 
and below. 



Comes and goes. 
suddenly. 



Absent. 



History of Injury. 



Absent. 



Frequently pres- 
ent. Slight. 



Almost certainly- 
present. Severe. 



90 



DIFFERENTIAL BETWEEN— Continued. 



Gonorrheal 
Arthritis. 



Rheumatic 
Arthritis. 



Pure Tubercu- 
lous Arthritis. 



Loose Body in- 
Joint. 



Specific complicat- 
ed urethritis. 



Negative. 



Young adult. 



Very infrequent 
in female. 



Not referred. Con- 
stant, grinding 



History of Disease. 



Negative. Negative. 



Previous Disease. 



Involvement else- 
where. 



Often secondary 
to lungs. 



Age. 



Over 40 



Adolescence. 



Sex. 



Pain. 



Varies with baro- 
metric pressure. 



Constant but 
worse at night 
if bone involved 



Disability. 



Often complete 
for long periods 
if over-exercised 
Remissions. 



100 to 102 during 
exaserbation. 



Depends almost! 
entirely on cli- 
matic conditionsi 
of temperature, 
pressure, mois-l 
ture, electrical 1 
state. 



Progressi ve ly 
complete. No 
periods of inter- 
mission. 



Temperature, 
Rarely elevated 



Evening rise 99 to 
101. 



Onset sudden. 



Not infrequently 
a sequel of trau- 
matic arthritis. 



Young adult. 



Male. 



Irregular exacer- 
bations at inter- 
vals when body 
i s caught i n 
joint. 



Complete with 
marked periods 
of intermission. 



Normal. 



GENERAL PHYSICAL. 

Inspection. 



Gleet. 



Swollen joints 
elsewhere. 



Pulmonary cavi- 
ties. 



Negative. 



91 



DIFFERENTIAL BET WEEN.— Continued. 



Gonorrheal 
Arthritis. 



Rheumatic 
Arthritis. 



Pure Tubercu- 
lous Arthritis. 



Loose Body in 
Joint. 



LOCAL PHYSICAL. 

Inspection. 



Dark red, swollen 
joint. 



Warm. (For local 
temperature, 
palpate with 
back of hand 
which is more 
sensitive than 
palm.) 



Often 1 to 2 inches 
enlargement. 



Often very little 
redness and mo- 
derate swelling 



Characteristically 
white, very mo- 
derate swelling. 
May be only ap- 
parent. 



Palpatk 



Cold. 



Colder than 
well knee. 



the 



Mensuration. 



in. to 1 in. 



Little or no en- 
largement. 



May be small lo- 
cal tumor show- 
ing position of 
foreign body. 



Hot, if recovering 
from exacerba- 
tion. 



Same as well side. 



LABORATORY FINDINGS. 
Puncture. 



Exudate. Sp. Gr- 
over 1010 and 
containing go- 
nococci. Much 
albumin. 



Transudate con- 



If present, transu- 
date. Sp. Gr. , 
1001-1005 Lit- taini °g °ccas- 
tle albumin. - J lonal 



No 1 



germs. 



germs. 



Effect of Drugs. 



Exudate, 
germs. 



No 



Negative. 



Negative save for 
partial relief of 
pain. 



Often very help- 
ful. 



Reaction from tu- 
berculin. 



Mechanical Treatmen 



Hydrotherapy and 
dry heat, may 
improve. 



Marked improve- 
ment under ex- 
tension and im- 
mobilization. 



Negativ3 



Freedom from at- 
tacks by immo- 
bilization. Oc- 
casionally cura- 
tive. 



92 



ISCHIO RECTAL FOSSA. 



Jfase of Triccngc/cLr //gamenr 

do+ttd. 2me skovts tti junt.t7.yi 

«•">% Scf/^r-ff^a.? fate*. 







7 fchio ■ Ca sernoju s 



ObrvrmTor 

Tajc/a. 



/fir? Tb<ffc 
Yesse?s a»<2 



Cr norrhotdL<t7 Oft 



9>«* 



Y* 



Cent-mi Join* ~K 
'* SCm. 



Fig. 16 



ISCHIORECTAL FOSSA. 

Two inches deep, one inch wide. 
Base formed by integument of ischio-rectal region. 
Apex at angle of division between obturator and recto-vesical fascia. 

Boundary. 

Base of triangular ligament. 

Its junction with the superficial fascia. (Dotted line) 

Obturator fascia. 

Tuber ischii. 

Great sacro sciatic ligament. (Note that it extends as 

far as coccyx). 
Gluteus maximus. 
Sphincter Ani. 
Levator Ani. (Owing to the fact that its insertion is 

on a lower plane than its origin). 
Coccygeus. (As it lies in same plane as the above). 

Internal Pudic Vessels and Nerve. 
Inferior Hemorrhoidal Vessels and Nerve. 
Superficial Perineal Vessels and Nerves. 
A Branch of 4th Sacral Nerve. 
Adipose Tissue. 



A n teriorly. — 1 . 

2. 
Externally. — 1 . 

2. 
Posteriorly. — 1. 



Internally. — 1. 
o 



3. 



C 071 tains. — 1. 
2. 
3. 
4. 



GONORRHEAL INVASIONS. 93 

: 



Ohi-uTccfor /-)-) + 
/$Cf>/o nzc+a.7 Toss a. 




Sfoh, 



*/0° £/eva.+<on of f^e ~/=>re c e on ncj 

Fig. 17 

One of the worst possible sequels of gonorrheal urethritis 
is gonorrheal prostatitis. Not infrequently it goes on to ab- 
scess, and although it now seems probable that the enlarge- 
ment of the prostate is due to gravitational rather than to infec- 
tious causes, it is at least not a good thing to have had a 
gonorrheal infection of the prostate. In a number of symptoms 
this condition simulates cystitis. 

There is a latent area immediately posterior to the pubic 
symphysis, the function of which is not understood, and which 
is therefore commonly looked upon as fortuitous in occurrence. 
This is probably erroneous, because it undoubtedly has some 
function. It is called the space of Retzius. In practice, how- 
ever, its chief function appears to be its liability to become in- 
fected. It is not frequently invaded by the gonorrheal organ- 
ism, but this accident may happen. In any event it may be 
necessary to differentiate such abscess formation from pros- 
tatitis and from cystitis. 

There is another possible sequel of gonorrheal urethritis, 
viz., ichio-rectal abscess. 



94 



DIFFERENTIAL BETWEEN GONORRHEAL 



Prostatitis. 



Cystitis. 



Space of Retzius 
Abscess. 



Ischio-Rectal, 

Abscess. 



History of Tumor. 



Negative. 



Marked when bo- 
wels move. Vio- 
lent and throb- 
bing. 



Tenesmus usually 
absent. Reten- 
tion common. 
Stream dimin- 
ished. 



101 to 104. 



Frequency of mic- 
turition, most 
marked at night 



Negative. 



Negative. 



Perineal 
nence. 



promi- 



Pain. 



Pain over bladder. 
Burning, con- 
stant. 



Marked retro-sym- 
physeal distress 



Disability. 
Tenesmus always 
typically pre- 
sent and se- 
vere. Retention 
rare. Stream 
normal. 



Tenesmus absent. 
Retention i m ■ 
probable. 
Stream normal. 



Temperature. 



100 to 103. 



101 to 104. 



Urinary Symptoms. 



Most marked 
day. 



by 



Negative. 



Over perineum. 



Ten.ab. Retention 
absent, except 
under very ag- 
gravated condi- 
tions. Stream 
normal. 



100 to 103, 



Negative, 



LOCAL PHYSICAL. 
Palpation. 



Pressure pain 
marked, pros- 
tate enlarged. 



Sero-sanguinous 
or purulent. 



Gross appearance 
normal. No 
blood or album - 



No pressure pain 
or prostatic en- 



largement. 



Tender ness on 
deep abdominal 
pressure. 



Exploratory Puncture. 



Absent. 



Absent. 



Tenderness 
perineum. 



Generally puru- 
lent. 



LABORATORY FINDINGS. 
Urine. 



Gross appearance 
changed. Tur- 
bid with fioccu- 
lent masses. 
Blood present if 
acute. (Albu- 
min due to pus) 



Normal. No albu- 
min or blood. 



Normal. No albu- 
min or blood. 



95, 



DIFFERENTIAL BETWEEN GONORRHEAL.— Continued. 



Prostatitis. 



Cystitis. 



Space of Retzius 
Abscess. 



Ischio-Rectal 

Abscess. 



If acute and cys- 
tic, Sp. Grav. 
1010 Alb. in ex- 
cess. Germs 
present. (Exu- 
date) 



Negative. 



Irrigation often 
helpful. 



Puncture Fluid. 



Absent. Absent. 



Drug Administration. 



Positive. 



Negative. 



Mechanical Treatmrnt. 
Negative. 



Irrigation c u r a 
ti ve. 



Dense, creamy 
fluid. Sp. Grav. 
1030. Many 
cells. Gonococci" 



Negative. 



Negative. 



CHAPTER IX. 
THE HEAD AND SPINE. 

Brain lesions are so frequently associated with scalp 
lesions and scalp lesions with those of the skull, that it is worth 
while to draw an analogy between the morphological relations 
of the hard and soft parts of the entire brain covering. 

The scalp and the skull, fortunately for the sake of one's 
memory, consist of three analagous concentric shells. There 
is a relatively soft sheet externally and a tough brittle sheet 
internally. Between these two corresponding sheets there is 
a soft and friable layer. 

Brain surgery has not made advances in the past five years 
commensurate with that of other more popular regions of the 
body. Eighteen years ago Weir and Seguin were just 
sufficiently advanced to localize a cortical cerebral tumor. They 
were able at autopsy to verify their findings. They did not, 
however, feel justified in advising operation. 

By clinical experience and by information gained through 
vivisectional work a very great degree of accuracy in brain 
surgery has been reached, but it must be confessed that even 
the surgery of the hitherto prohibited chest cavity is probably 
more advanced than that of the brain. 

It is not that the brain or the cord offer insurmountable 
technical difficulties, but rather that in from 80 to 90 per cent, 
of cases, the possibility of reaching a positive differential is 
denied us. Surgeons do not yet feel justified in making ex- 
ploratory incision of the spine or cord with the same freedom 
that they do in the case of the abdomen. This is partly be- 
cause the immediate danger is greater, and partly on account 
of the difficulty of interpreting and correctly judging conditions 
after exploration is made. 

There is, however, a small number of reasonably well 
determined lesions within the brain case, upon which a satis- 
factorily certain differential can be made. One of the most 
common, as well as most practical, is a differential between 
the classical causes of compression. 



* DIFFERENTIAL BETWEEN 



u: 



Bone. 



Bloou. 



Bugs. 



Body. 
(Foreign) 



Present. 



Onset immediate. 



History of Injury 
Present. Present or absent. Present. 



Onset slow and ir- 
regularly pro- 
gressive . 



Disease. 

36 to 72 hours. 



Normal. 



Immediate and 
continued. 



Temperature. 

100 to 102. (Clotj 102 to 105. (Tox- 
absorption.) ins) 

NERVOUS SYMPTOMS. 

Unconsciousness. 

Immediate, due to 
concuss'n. Vom- 
iting. Recov- 
ery. Localized 
convulsions and 
unconsciousness 
within variable 
time. Depends 
on rate of hem- 
orrhage. 



Immediate. 



Normal. 



Delirium, loss of 
consciousness in 
final stage. 



Immediate. 



Exploratory Incision. 



Spicules of inner 
table. 



Free blood. 



An exudate. 



Bullet or the like. 



* Note that these all begin with "B" 

It will thus be seen that the differential between these four 
causes of compression depends practically on the character of 
the onset of unconsciousness and upon the temperature. 

It is always difficult to differentiate the conditions and find 
the true one which has caused a person to be unconscious. 
Among the many possible cerebral causes of unconsciousness, 
there are four, the first three of which have frequently to be 
differentiated. As presented in the following columns, the 
first two occur synchronously under most conditions, that is 
to say, the second cannot be present without a certain degree 



FISSURES. 




T±oi-rubtT<r*c<: 

'won) 



(* 



CXJM 



Fig. 18 

Shows relation of fissures to surface. Note relation of Reid's Base Line to 
Inion. Compare position of proximal end of Fissure of Rolando with 
position for trephining for middle Meningeal, shown in Fig. 19. This 
explains symptoms of surgical hemorrhage as given in differential. 

Rolando. — Draw line from Root of Nose to Occipital Protruberance over 
the convexity of the head. On this line mark off point .557 of the 
distance from before backward. From this, a line is projected, run- 
ning downward and forward '6% inches at an angle of 67 tf to the pre- 
viously mentioned line — this represents the fissure of Rolando. 

Sylvius. — Draw line \% inches back from Extl. Angular Process, || to 
Reid's Base Line — Erect a quarter inch _|_ to this and from the tip of 
this J_ carry a line up and back to meet a _|_ dropped % in. from the 
Parietal eminence — giving Fissure of Sylvius. 

Parieto-Occipital Fissure: — By prologing Fissure of Sylvius to median 
line. 



DIFFERENTIAL. 



99 



of the first. Their symptoms are differently given by different 
authors, and they are well known to overlap and interdigitate 
most confusingly. 

The first and the third are always synchronous. The 
differential referred to is between, old friends. 

DIFFERENTIAL BETWEEN 



Concussion. 



Compression. 



Contusion. 



Grand Mal. 



Always present. 



Onset sudden. 



Negative. 



Sign of regaining 
consciousness. 



Sphincters may be 
relaxed. 



96 to 99. 



History of Injury. 

Always present. 

History of Disease. 



Very frequently 
present. 



Onset may be slow 



Onset slow. 



Negative. 



Malformation. 



Negati 



Vomiting. 



Not frequent. 
Never present 
after brain pres- 
sure is well de- 
veloped. 



Frequent. 



Emptied only in 
early stage if at 
all. 



Absent. 



Onset accompani- 
ed by aurae. 



Stigmata. 



Absent. 



Bladder and Rectum. 

Typically emptied 

Temperature. 



101 to 102. 



to 101. 



Pulse. 



Weak, 120; irreg-'c « n 

ular, deficient, Strong, 60; regu- 
short, compress- 



ible. 



lar, bounding, 
long and full. 



Same as in com- 
press io n, but 
rises to 100. 



Rarely emptied. 



Normal. 



Normal. 



LofC. 



100 



DIFFERENTIAL BETWEEN— Continued. 



Concussion. 



Compression. 



Contusion. 



Grand Mai, 



Respiration. 



Shallow, sighing, 
30. 



Sterterous, puff- 
ing, 8 to 14. 



No characteristic 
change. 



Sighing, 20. 



NERVOUS SYMPTOMS. 
Central. 



TJ n consciousness 
incomplete. Can 
be roused. 



Often present. 



Face white and 
wet. 



Pupils react. Un- 
equally irregu- 
lar. 



May be exaggerat- 
ed. 



U n consciousness 
absolute. Can- 
not be roused. 



U n consciousness 
incomplete, but 
can be roused 
with difficulty 
onlv. 



Convulsions. 



Absent, except 
when pressure 
very high. 



Depends on posi- 
tion of tear. 



GENERAL PHYSICAL. 

Inspection. 



Face red and dry. 



Face red and drv 



Superficial Reflexes. 



Dilated. Do not 
react. 



Dilated, 
react. 



Do not 



Diminished or ab 
sent. 



Deep Reflexes. 

Exaggerated. 



U n consciousness 
complete. Can- 
not be roused. 



Present. 



Normal color, no 
sweat, contor- 
tions frequent. 



Pupils dilated. 



Diminished or ab- 
sent. 



These represent some of the most important differential 
points. So great is the variability in the symptoms presented 
by these lesions that just exception may be made in the case of 
almost every attempt to differentiate them. Authorities differ 
widely in their statements as to the symptoms, it being impos- 
sible to find two text books which agree on every point. It 
would be easy to forecast what the symptoms should be in any 
one of these conditions, if a thorough understanding of the 
pathology were possible. 



CONCUSSION, COMPRESSION, CONTUSION. 101 

Brewer states that contusion is always associated with 
concussion. The symptoms of concussion appear first and 
cloak those of the more serious lesion. His few pages devoted 
to these subjects render them clearer than chapters of other 
text books. 

Concussion is like shock in symptoms, but not in gross 
pathology. It is characterized probably by a less extensive 
degree of cerebral anemia. It differs from shock further in that 
it is complicated by symptoms of brain tearing. Pure concus- 
sion, then, is a hypothetical lesion. Did it exist, it could prob- 
ably not be differentiated from the apathetic form of shock. 
It is due either to atomic or molecular upheavals, if such divi- 
sions of matter exist. In a measure it resembles neuralgia of 
peripheral origin, which is supposed to have an origin in mole- 
cular disturbance. Practically, however, all one needs to re- 
member is that the symptoms of shock and of concussion may 
be virtually one. 

Compression is a somewhat more definite lesion. It is 
very easy to understand that although hydraulic pressure nor- 
mally is transmitted equally in all directions, the tightness of 
the falx and tentorium membranes must considerably retard 
the equalization of this pressure. Compression symptoms de- 
pend, then, partly upon the position of the pressure producing 
lesion, particularly if this be fluid. They depend also upon the 
period of the illness at which the patient is seen. This, of 
course, is true of all diseases. Symptoms are rarely stationery, 
and, for this reason, it is utterly impossible to give a differen- 
tial that may not be open to criticism, because it is very difficult 
to stipulate the exact period at which the observations recorded 
are made. 

The reflexes of the eye and the condition of the vesical 
and rectal sphincters afford but unsatisfactory evidence be- 
cause of their variability. 

Contusion. — This symptom is usually seen as a sequel of 
concussion. The unfortunate subject of this lesion is not in- 
frequently driven from hospital to hospital under the suspicion 
of malignering. This is not the fault of those who examine 
him, but because the symptoms of cerebral irritation are, in 
their early stages at least, indistinguishable from the group 



102 SYMPTOMS OF CONTUSION. 

often craftily imitated by men and women suffering from 
hospitalism. Where 10,000 useless degenerates are turned 
aside from the hospitals and prevented from preying upon the 
public, one also is turned aside who has the real symptoms 
of cerebral irritation. 

In more advanced stages the symptoms are characteristic, 
but even then the victim may easily be mistaken for a bad 
tempered derelict. This is important to remember in differen- 
tiating cerebral irritation. 

Picture an old "Bowery skate" who has come into the 
hospital and has been assigned to a bed. Unless prevented, he 
will insist on wearing his ragged coat. He is indisposed to pull 
his dilapidated pants off. With one suspender over his 
shoulder he lies on the comfortable bed in a typically tetanoid 
position, that is to say, with all the joints in moderate flexion. 
His eyes are closed, his face is apathetic. His bowels are not 
lost to control, and his urine flows normally. He resents inter- 
ference with an oath. Because of his irritability, he is shunned 
by the other patients who regard him as a crank. Unless he is 
carefully watched, he will empty his bowels in the bed, because 
it appears to be too much exertion for him to go to the toilet. 
He will eat, but only if food is brought to him ; he will not go 
and hunt for it. In short, he presents a typical picture of an 
irritated recluse suffering from a severe "grouch." 

This picture, of course, is that of a mild and chronic case. 
Cerebral lesions, causing irritation, may, be so profound as to 
be unmistakable. 

BRAIN HEMORRHAGE. 

This may conveniently be divided into two types, the 
medical and the surgical. The medical usually occurs from 
the lenticulo-striate artery (Charcot's), the largest branch of 
the middle cerebral. It is poorly protected, and is known to 
undergo atheromatous change of an advanced type early in 
the course of that disease. Its walls do not increase propor- 
tionately in strength as the vessel dilates from over cerebration. 
It is consequently dilated and is apt to become atheromatous 
in men of profoundly active minds. Osier calls pneumonia the 
friend of the aged. Apoplexy may well be called the friend of 



TREPHINE AREAS, 



103 



the thinker. Unfortunately, it is as yet beyond the pale of 
surgical intervention. Medical hemorrhage is more common 
than the surgical form. 




7P&h$ t . 

Clrt.b%)tvnt 



Fig. 19 
SOME TREPHINE AREAS. 
Reid's Base Line — Lower margin Orbit to External Auditory Meatus. 

Trephine for Middle Meningeal. — \y 2 in. above Zygoma; \y> in. back 
from external angular process. 

Trephine for Brain Abscess. — ^ in. above External Audit. Meatcus ; — 
if not there, 1% inches behind external audit, meatcus: % in. below 
R. B. L. (Cerebellar Abscess) 

Trephine for Lateral Sinus. — 1 inch behind Auditory Meatus; % in- 
above R. B. L. 



104 



SENSORI-MOTOR AREA. 
Fig. 20 




r* 



,f°' 



MoVfLflZNTS »r 






id 







..... Siap 1 * 



/yoTor SFliCH 



• Sound 
Fig. 21. 



POSITION OF THE CENTERS. 105- 

Surgical hemorrhage generally comes from the anterior 
branch of the middle meningeal artery. Its extent is deter- 
mined by two factors, namely by the degree of laceration and 
by the position of the wound. Not infrequently the middle 
meningeal lies in somewhat more than a 180 degree channel 
on the skull case. This amounts virtually to a canalization of 
the bone by the vessel, and from it two interesting conclusions 
result. First, hemorrhage must take place from an artery 
which is enveloped by bone, but very slowly, if at all ; and 
second, the artery must be injured in almost every case of 
simple linear fracture of the bone across its course. The rela- 
tion of the dura to the tear is also a determining factor in blood 
extravasation. Hemorrhage will naturally take place very 
much more rapidly central, rather than peripheral, to this 
tough membrane. Cases of peripheral dural bleeding have been 
known to occupy a week or more before symptoms became 
marked. This is to be explained by the difficulty which the 
blood experiences under the limited cardiac pressure in tearing 
the dura from the bone. 

The home-made method of remembering the position of 
the centers in a sensory motor area is shown in the accompany- 
ing figure. It demonstrates the body of a puppet upside down, 
which is the position taken by the centers, as shown by the 
companion figure. It demonstrates further that just posterior 
to the fissure the sensory and the motor areas overlap each 
other. This little scheme has long been used by Dr. Robert H. 
Dawbarn in demonstrating his lectures on the brain. 

The position of the anterior branch of the middle men- 
ingeal is such that the first symptoms, after the recovery of 
the unconsciousness produced by the primary concussion, 
should, as shown by the puppets in the Figure be motor irrita- 
bility of the face and arms. 

BRAIN a:nd membrane inflammations. 

There is no more favorable location for the growth of 
bacteria than within the brain case. There are various ways 
by which these germs obtain ingress. It may be convenient to, 
use Sub-Scheme III to give the causes of intra-cranial infection. 
It may be brought about by T. I. D. M. of the parts. 

Of tumors situated externally, epitheliomata may be taken 



106 CONTINUITY AND CONTIGUITY. 

as representative. These, as nutritional advantages decrease, 
break down and become infected. The drainage from such 
ulcerating areas is apt to be by one of the Emissory Veins. 
This is more apt to be the case if the lesion under consideration 
is located upon the scalp, although the face, as shown by the 
figure, is not a region exempt from danger. Suppose drain- 
age of the epithelioma to take place via the ophthalmic 
vein. It terminates in the cavernous sinus, and from this great 
blood lake infection travels into the brain by contiguity of 
tissue. (See Fig. 13) 

It is important to know the difference between travelling 
by continuity and contiguity of tissue. It would be easy to 
understand the terms if the words "of tissue" were usually 
used, but they are not. If an inflammatory process begins in 
the stomach, as an ulcer and an abscess developes in the con- 
tiguous lobe of the liver, that infection is said to have reached 
its destination by contiguity. The tissues were near to each 
other, but they were not continuous. First, there were stomach 
?ells, then interval connective tissue cells, then liver cells. 

If, however, an abscess had formed in the wall of the 
stomach, those products would have reached their destination 
by so called "continuity of tissue," because they never were 
obliged to pass out of the stomach wall. 

Consequently, by contiguity,- a panencephalitis might be 
established in the case of the supposed ulcerated epithelioma. 

Sarcoma of the Antrum is an example of a tumor in the 
wall of the brain case, which, on breaking down, may cause 
panencephalitis, localized intra-cranial abscess, or any form of 
inflammatory change. 

Tumors on the inner wall of the brain case, which cause 
intra-cranial inflammation, are rare. 

External Injuries. — Almost any injury which becomes in- 
fected, and which is situated in the neighborhood of an emis- 
sory vein, may cause the lesion under consideration. 

Fractures are the next possibilities to consider, and after 
injuries come the diseases. 

Lupus. This disease is prone to ulceration, and the man- 
ner of infection from it may be similar to that of epithelioma. 

Otitis Media often affords an admirable illustration of 



CEREBRAL ABSCESS. 107 

how infections travel by contiguity of tissue. From the middle 
ear, as has already been noted, the agents travel to the mastoid, 
thence to the lateral sinus, producing typical phlebitis of the 
internal jugular; thence, if the patient lives, to the dura, pro- 
ducing pachymeningitis ; thence to the pia (always supposing 
the patient to stand it), producing lepto-meningitis ; thence to 
the cortex, producing cortical abscess ; thence to the enceph- 
alon, producing pan-encephalitis. 

Cerebral Abscess, then, may arise in a variety of different 
ways. It is not unlike abscesses elsewhere. It, therefore, pos- 
seses the general characteristic that it may be due to a pure 
or a mixed culture infection. 

The best example of pure culture cerebral abscess is the 
tubercular. About this abscess an interesting point of dif- 
ference has arisen. The chronic, slowly developing, often mul- 
tiple, frequently secondary, pure culture tuberculous abscess 
causes typically a sub-normal temperature. Its antithesis, the 
single, acute, rapidly growing mixed infection abscess which 
bears no practical relation to the tuberculous form at all, cer- 
tainly in its early stages, is characterized by a temperature of 
from 103 to 105. 

Park states that the temperature when raised is in pro- 
portion to the degree of meningeal involvement. He says fur- 
ther that a particular characteristic of the cerebral abscess is 
its tendency to form about itself a pyophylactic membrane bv 
which the abscess becomes entirely capsulated. In fact unless 
this membrane forms, the patient is almost certain to succumb 
in the acute stages of the abscess. Thus, "walling off" is of 
vital importance in the brain. 

It is not known why abscess tends to produce a sub-normal 
temperature. If it were a usual accompaniment of intracere- 
bral pressure, one would expect to find it a manifestation of 
tumor ; but such is not the case. There can be little doubt that 
whatever the cause of the subnormal temperature acute ab- 
scesses, which undergo the encapsulation process, become prac- 
tically the same as pure culture tubercle abscess. They are in 
other words "cold" and should naturally not be expected to 
produce the symptom of elevated temperature. The conclusion 
then is, that although probably a number of cases of abscess 



108 



CEREBRAL DIFFERENTIALS. 



which in the past were described as mixed culture abscesses, 
have in reality been pure culture tubercular formations. In 
this case, a subnormal temperature has erroneously been as- 
cribed to them. 

One of the most frequently asked as well as the most con- 
fusing differentials, is between cerebral tumor, abscess, tuber- 
culous meningitis and typhoid. It is obviously of the gravest 
importance for the patient that correct conclusions should be 
reached early because of the fundamental difference in the 
modes of treatment. In this differential, as in others, no at- 
tempt is made to give all the smallest details which are in- 
tended to be filled in by the reader. Furthermore, here as else- 
where, it is not possible to be dogmatic without opening a free 
path for justly unfavorable criticism. Whatever flavor of dog- 
matism is present has been extracted from the most recent 
text books on the subject. 

DIFFERENTIAL BETWEEN 



Cerebral Tumor. 



Cerebral 
Abscess. 



Tuberculous 
Meningitis. 



Typhoid Fever. 



Not rare, especi- 
ally in sarcoma- 
ta. 



Onset fairly rapid 



Before 20 if tuber- 
cle; 20 to 40 if 
sarcoma. 



Very severe. Con- 
stant. Some- 
times located 
over lesion. 
Worse in early 
morning. 



Frequently fol- 
lows fracture 
of skull. 



History of Injury. 
Absent. 



Disease 
Onset slow. Chill. 



Onset slow, 
elsewhere. 



T.B. 



Age. 



Active adult life. 



Childhood. 



Pain. 



Severe. May be 
localized. 



Absent. 



Onset slow. Anor- 
exia. Nosebleed 
common. 



15 to m. 



Often worse at Headache often 



night. 



absent. 



109 



DIFFERENTIAL BETWEEN.— Continued. 



Cerebral Tumor 



Cerebral Abscess 



Tuberculous 
Meningitis. 



Typhoid Fever 



Disability 



Depends on posi- 
tion. May be 
anywhere. 



If protectile or dis- 
tinctly "cere- 
bral" in type 
very important. 



Because of fre- 
quency in cere- 
bellum, often 
disturbances of 
gait. 



Stiff neck. 



Vomiting. 



Not infrequent, 
but nausea rare. 



Not characteristic 



Dysalimentation. 



If present, of dis- 
tinctly "gastric ' 
type. 



Negative. 



Normal. 



Bladder and Rectum 
Negative. 

Temperature 
96.5 to 100. 



May be secondary 
to enteric T. B. 
If so, diarrhea. 



100 to 102. Even- 
ing rise. 



Pulsk. 



Strong, 50, regu- 
lar. 



Not common un- 
less in cerebel- 
lum. 



Late, if at all. 



If present, abso- 
lute. 



Usually general 
and early. 



Strong. 40 to 50, 
regular. 



Strong, 60 to 70, 
regular. 



NERVOUS SYMPTOMS. 

Vertigo. 



Very common. 



Absent. 



Delirium. 



Apt to be earlier. 



Early. 



Unconsciousness. 
Absolute. Less profound. 

Convulsions. 

Not so common as ^ 
in tumor. Common. 



Constipation o r 
diarrhea. 



100 to 102.5. "Step- 
ladder". 



Weak, 100 to 110, 
may be irregu- 
lar. 



Absent, except 
from gut or due 
to weakness. 



Early, late or ab- 
sent. 



Less profound. 
Often intermit- 
tent. 



Very rare. 



110 



DIFFERENTIAL BETWEEN.— Continued. 



Cerkbral Tumor 



Cerebral Abscess 



Tuberculous 
Meningitis. 



Typhoid Fever 



Amnesic Aphasia. 



Word- deafness, 
common. 



Rare. 



Word - blindness. 



Not so common. 



Absent. 



If in tempero- 
sphenoi dal, 
common. 



Motor Aphasia. 
Absent. 



Alexia. 



Less common. 



Absent. 



Agraphia 



Oft en cannot 
write, 
or t h i ] 

frontal) 



write. (Second -r, „ 
or third left! Rare ' 



Absent. 



Absent. 



Absent. 



Absent. 



Absent. 



Frequently pres- 
ent. 



Frequent. 



Optic neuritis 
common and of- 
ten double. 



Apraxia. 
(Loss of Perception of Objects) 

Occasionally pres- 1 Ah „_ T|t 

ent. ^Dsent. 

Paresis or Palsies. 



Occasional. 



Not so common 
and apt to be 
single. 



Absent. 
Special Sense. 
Absent. 



Absent. 



Absent. 



Absent. 



LOCAL PHYSICAL. 
Palpation. 



Negative. 



Occasional local 
increase in tem- 
perature. 



Very rarely local Not infrequently 
tenderness. local tenderness 



Negative. 
Percussion. 
Absent. 



Negative. 



Absent. 



Ill 



DIFFERENTIAL BETWEEN— Continued. 



Cerebral Tumor 



Cerebral Abscess 



Tuberculous 
Meningitis. 



Typhoid Fever 



Exploratory Incision. 



Found to be oper-, 111 S^ftX^S" 

, , . , K. , I oidal lobe or ce- 
able m only 5 to rebellum . Lo _ 



10% of cases. 



Unaltered. 



Negative. 



If gumma, mark- 
ed. 



calized pus. 



Pin-point tuber- 
cles on mem- 
branes. Exu- 
date. 



Negative. 



BLOOD. 
Leucocytosis. 

10,000 to 15,000. ' 9000. 
I 
Widal and Other Tests. 



Negative. 



Negative. 



Effect of K. I. 



Positive to tuber-' 
culin. 



5000 



Positive to Widal. 



Negative. 



Negative. 



It will thus clearly be seen that a differential between these 
four diseases, particularly if they are taken at a reasonably 
early period of their development, is extremely difficult. The 
value of the laboratory findings cannot be over estimated, for 
clinically there may be a very grave and discouraging absence 
of facts. 

THE SPINE. 



If difficulty has been experienced in localizing cerebral in- 
juries, it has been much greater in the case of the cord. This 
is obviously because the cord is concerned only with reflex ac- 
tion and with transmission. These functions, are extremely 
difficult to localize with any degree of accuracy. Precisely 
similar lesions arise in the cord as in the brain and their causes 
are in a measure identical with those affecting the higher cen- 
ters. It often becomes necessary to establish a differential" 
between a supposed case of spinal hemorrhage, of bone pres- 



112 



SPINAL DIFFERENTIALS. 



sure of transverse lesion of the cord, or of certain very rapidly 
growing tumors. In theory this may be possible, but in prac- 
tice most unfortunately it is too true that a positive conclusion 
can be reached only after exploratory incision. There are, 
however, points of academic interest and these have been ar- 
ranged as concisely as conflicting opinions of authorities allow. 

DIFFERENTIAL BETWEEN 



Spinal 
Hemorrhage. 



Bone Pressure. 



Transverse Mye- 
litis. 
(Traumatic) 



Sarcoma. 



Always present. 



Onset may be 
slow. -Symp- 
toms increase. 



Atheroma. 



History of Injury. 



Always present. Always present. 



History of Disease. 
Onset immediate. 



Symptoms sta 
tionarv. 



Same. 
Previous Disease. 



Negative. 



100 to 102. 



Appear late. Mod- 
erately slow in- 
crease. 



Often irregularity 
of spine. 



Negative. 



Negative. 



Normal. 



Negative. 
Sex. 

Negative. 
Temperature. 

98 to 100. 



Paresis and Paralysis. 
Immediate. Immediate. 

LOCAL PHYSICAL. 

Inspection. 



Absent. 



Relatively very- 
slow. Symp- 
toms increase. 



Involvement else- 
where. 



30 to 40. (McCosh) 



Normal. 



Appear late. Slow 
increase. 



Same. 



Same. 



Negative. 



LAMINECTOMY. 118 

It will be seen that there are very few available data upon 
which to base a differential of the spinal lesions. Brewer says 
that a recognition of extra-dural and subdural hemorrhage is 
surgically unimportant even if they do occur unassociated with 
fracture or dislocation, because they cannot be clinically recog- 
nized. 

Laminectomy is the term used to designate the technic 
which is used in reaching the cord. The danger of this opera- 
tion increases very rapidly as it approaches the brain. The 
chief matter of importance concerning it is that if indicated at 
all it should be performed immediately. It is interesting that 
this rule, which was formerly supposed to hold good for in- 
jured nerves, has recently been demonstrated, as already cited, 
to be fallacious. (See chapter on nerves.) That this does not 
hold true in the case of the cord is undoubted, for degenerative 
processes of a destructive nature are pretty definitely proven to 
be well under way thirty-six to forty-eight hours after the cord 
has been injured, and by some authorities before then. 



CHAPTER X. 
THORAX. 



Fig. 22 

The Complemental Sinus 
is shown as the higher of the 
two areas mapped out on the 
lower region of the Thorax. 
It is that space intervening 
between the lower border of 
the lung and the line of Re- 
flection of the Pleura and is 
filled with Pus in non-en- 
cysted empyema. 

The Cos to Phreiiic Sinus 
lies just below the comple- 
mental and its inner and 
outer boundaries are formed 
respectively by Diaphragm 
and Thoracic wall. This 
Sinus is the seat of Costo 
Phrenic Abscess. 

The following table, in part 
compiled according to Hunt- 
ington will be found useful. 

Fig. 23 





C/f s. 



Complemental and Supplemental 
Sinus. 



Lower Pleural 
Line. Limit. Lung. 

Sternal— Upper VII. Rib. Upper VI. 

Parasternal — Middle VII. " Lower VI. 

Mammary— Lower VII. " Upper VII. 

Axillary— IX. " Lower VII. 



Comple- 
mental 
Sinus. 

2 cm. 

2 cm. 

2 cm; 

G cm. 



Vertebral- 



XII. 



XI. 2.53 cm. 



This shows a longitudinal elevation 
through the centre of Fig. 22. Con- 
sult Deaver's anatomy for further 
data. 



Note thai the greatest depth of the 
Complemental Sinus is in the axillary 
line. 

The Costo Phrenic Sinus naturally 
is bounded above by the Lower Pleural limit and below by the attachment of 
the diaphragm to the Ribs and Rib-Cartilages, (See cut of diaphragm in 
chapter on hernia.) 



DIVERTICULAE. 115 

The surgery of the thorax has been stimulated very much 
by the perfection of methods for artificial respiration pending 
the opening of the chest cavity. Prominent among these is 
one devised by Matas of New Orleans. It is so constructed 
that it automatically supplies the required amount of air. This 
obviates the danger of the variable dosage which the excite- 
ment of a major operation was almost certain to engender 
when the old instruments were used. 

The Esophagus, partly because of its great importance and 
its unfortunate liability to disease, besides the fortunate fact, 
that although passing through the thorax, its whole extent can 
be reached without opening that cavity, has been the object 
of more surgical intervention than any other organ in the chest. 

One of the most interesting lesions which can befall this 
tube is the formation in it of Diverticulae. The causes of these 
diverticulae can easily be enumerated by reference to Sub- 
scheme III. They arise as a result of twelve possible condi- 
tions, viz. — Tumor. Injury, Disease or Malformation within the 
lumen, in the wall of the lumen and without the lumen, or in 
other words in twelve possible positions. The accompanying 
radiogram, which was recently made by Dr. Cole at Roosevelt 
Hospital, shows the nature of these diverticulae very beauti- 
fully. The outline was made clear by causing the patient to 
swallow about two ounces of carbonate of bismuth. The 
esophagus, on account of its being, collapsed antero-pos- 
teriorly, appears in this side view as a line. 

These diverticulae are often the result of stricture. 

Dunham has recently shown that almost every stricture 
which is of such nature that the patient is not prevented by it 
from swallowing water, can be passed by allowing a thread to 
float in the water and by then swallowing the liquid and the 
line. In strictures of the deep esophagus, which are beyond 
the reach of external esophagotomy, and as a preparatory to 
Abbe's Fish Line Treatment, this demonstration is of great 
importance. 

The Italians have been the pioneers in Cardiorrhaphy. As- 
tonishing success has met efforts to suture the heart wall. It 
depends upon the introduction of interrupted sutures which are 
tied during diastole. 



116 



ESOPHAGUS. 




ESOPHAGUS 



Fig. 24 



ESOPHAGEAL DIVERTICULUM. 

(author's case) 

Given off opposite the 6th cervical vertebra. (The patient coughed 
up bismuth for two weeks after this radiogram was made.) 



TREATMENT OF EMPYEMA. 117 

Of operations which necessitate a trans-pleural route, by 
far the most frequent are those for the relief of empyema. 
They may be enumerated as follows: (i) Paracentesis, (2) 
Resection of One or More Ribs, (3) Estlander's Operation, (4) 
Schede's Operation. (This last might be spelled "Shady" for it 
is highly doubtful if the patient survive it), (5) Fowler's Oper- 
ation. 

If the collection of fluid in the pleura be localized and of 
such extent as to produce a bulging ; a condition uncommon 
but not by any means unknown, the needle should, after most 
scrupulous sterilization, be driven in over the most prominent 
part of the swelling. If, however, as is more frequently the 
case, the exudate is not loculated. a point of election for para- 
centesis is just below the scapula. This of course is a very 
movable point, but it is usually understood that the arm is in 
a position past full abduction from the body. This raises the 
lower scapular angle somewhat and carries it toward the axilla. 
The needle should not enter lower than the eighth intercostal 
space, and when it is withdrawn, a piece of zinc oxide adhesive 
plaster should be clapped over the wound before the patient 
has time to suck air in through it by making a respiratory 
effort. 

Now suppose the pumped out fluid to have been a simple 
straw-colored liquid, which is shown by laboratory examina- 
tion, to have the characteristics of an exudate. This treatment 
will, in a very large percentage of cases, be curative. Occa- 
sionally, however, either because of infection introduced at the 
time of operation, or because of a contamination of the exudate 
through internal sources, the patient's condition will not im- 
prove except in so far as he becomes more comfortable at once 
from the relief of pressure. The temperature, instead of re- 
maining normal or falling from the slight rise which occasion- 
ally accompanies simple pleuritic exudation, either maintains 
that slight rise regularly, or else creeps slowly upward. What 
is to be done in the face of these conditions? 

Obviously drainage is indicated. Some very excellent au- 
thorities have said that adequate drainage is to be had through 
an intercostal space. Dr. A. A. Moore has devised an ingen- 
ious little instrument for so draining these pus cavities, partic- 



118 ESTLANDER'S TECHNIC. 

ularly in little children. The general consensus of opinion, 
however, is that it is better surgery in every case to resect a 
rib, rather than to attempt intercostal drainage. Ribs regen- 
erate very rapidly and, the resection entails a remarkably small 
amount of shock. On a "stiff" it is demonstrably impossible to 
do a sub-periostial resection, but this is simply because the 
membrane in the "stiff" is normal. In the case of a chronic 
empyema, however, the periostium is very apt to have become 
somewhat thickened on account of contiguous productive in- 
flammatory change. The section of rib, consequently, in these 
cases, shells out with comparative ease from its enveloping 
membrane. The intercostal vessels and nerve, below, are not 
seen if the periostium be split directly over the anterior long 
axis of the. bone, nor are the smaller vessels,, which are located 
at the upper margin. 

Now suppose the rib resection, and the introduction of the 
usual drainage tube to have failed. What is the next step to 
be taken ? Obviously it is necessary to establish freer drainage. 
The condition will now have become decidedly chronic, a 
greater or lesser area of the lung having retracted. The me- 
chanics of the proposition therefore become simple. A con- 
stantly discharging abscess is in one respect like nephritis in 
that the body in each condition loses highly nutritive albumin- 
ous fluids. The cavity has to be obliterated, in order to stop 
this steady drain of pus. It resolves itself into either bringing 
the lung out to meet the chest cavity or of dropping the chest 
wall upon the permanently collapsed lung. Obviously it is bet- 
ter for the patient if the lung can be forced out, but this cannot 
be done in all cases. 

Estlander's Operation is based upon an acknowledgment 
of defeat. It is therefore not indicated until every means, such 
as blowing water into James' Bottles and other attempts at pro- 
ducing artificial emphysema have been tried. Furthermore, it 
is not likely that any serious attempt to collapse the chest wall 
will in future be made until Fowler's technic, shortly to be 
spoken of, has been tried. If employed as thoroughly as is rec- 
ommended by its distinguished inventor, there must be very 
few cases in which it will fail to obviate the necessity of doing 
either an Estlander or a Schede. Suppose, however, Fowler's 



FOWLER'S TECHNIC. 119 

technic to have been unsuccessfully employed. One should not 
at this stage think of doing a Schede, but would naturally turn 
to the more conservative Estlander technic. He advises 
(Brewer) "the removal of portions of several ribs according to 
the size and shape of the underlying cavity, but without dis- 
turbing the thickened parietal pleura." 

Schede's Operation (Brewer) "consists not only of remov- 
ing the ribs but also the parietal pleura. He advises 'a large U 
shaped incision, beginning near the junction of the second rib 
and costal cartilage, extending downward and backward to the 
tenth rib, then upward to the axillary border of the scapula.' ' 

Fowler's Operation. It was noted some time ago that if, 
during the execution of one of these throracoplastic operations, 
the visceral pleura was cut, the lung promptly expanded be- 
neath it, so that the simple line of incision could, as one 
watched it, be seen to develop into an opening shaped like a 
bi-convex lens. It must be remembered that after the establish- 
ment of chronic empyema, the visceral pleura has promptly 
lost all its delicate physiological functions and, because of its 
extreme thickness (sometimes amounting to as much as a quar- 
ter centimeter) has begun to act as an ever tightening con- 
strictor around the lung. The evil effects of a productively in- 
flamed capsule of any organ cannot be overestimated ; its 
agency in producing lesions of the kidney will be spoken of 
later. 

Cutting the blanket-like pleura was destined to afford re- 
lief of a measurable but inconstant type. The technic some- 
what resembled the subcutaneous section of the fascial bands 
in Dupuytren's contracture, which, although giving temporary 
relief, eventually made the contracture worse by the subsequent 
increase of the scar tissue. 

Fowler was the first to note that the treatment of the 
pleura should be the same as the treatment of Dupuytren's 
fascia, viz. — that it should be removed as entirely as possible. 
He therefore advised that it be freely incised and ripped from 
the lungs. Obviously this should be done early, before dry 
productive inflammatory (sclerotic) changes have taken place 
in the lung. After the unfortunate establishment of this con- 



120 



MALIGNANT DISEASE OF BREAST. 



dition, there is no relief for, nor means of obliteration of the 
pus cavity, save by dropping the chest wall in upon it as pro- 
posed by Schede. 




a., a, CL. i ~9rnr>t^t » •£■ 

6. =/77*7 7Tfa7nm«T-y Orrery 



Fig. 25 

This is an adaptation from a most beautiful cut in Eisendrath's 
Clinical Anatomy. It shows the breast quadrants and their 
lymphatic drainage. It also shows the very important rela- 
tions of the internal mammary artery. 

(Used by courtesy of Db. Eisendrath) 



THE BREAST. 

Since a small fraction over one-half of all favorable cases 
of carcinoma of the breast can be permanently freed from the 
disease, it is indeed a pity that more do not reach the surgeon. 

An eminent authority has divided women into three 



DEGENERATION OF BENIGN GROWTHS. 121 

classes. Forty-five per cent, of them are so frightened at the 
possibility of having a tumor in their breast that they are per- 
petually running to their physician, or at least to the person 
who poses as such — for confirmation or refutation of their sus- 
picions. 

Another forty-five per cent, are so badly frightened that 
when they find a tumor in their breast, they conceal it from 
everybody and not a soul knows of it until it is a rotten mass 
heralded by its stench. 

The remaining ten per cent, are sensible about the matter. 
Immediately on discovering a small tumor they put themselves 
under the care of a competent surgeon. 

Of the first class, almost the entire number, because of 
their dread of the knife and their willingness to submit to every 
"ism" and "no-knife treatment," fall in discouragingly great 
numbers into the hands of the charletan and of the ignorant 
but well meaning practitioner of "isms." Thus it is that prob- 
ably not over twenty per cent, of tumors of the breast of a 
malignant character are ever subjected to suitable treatment. 

So hazy is the border line between an adenoma and a car- 
cinoma of an inactive type, that it is impossible to say, when 
the one may fade into the other. The changing of a benign into 
a malignant growth may be likened to the peeling off from a 
sweating hand of a pair of moist kid gloves. The fingers turn- 
ing inside out, reverse their direction. That is all, from mor- 
phological evidences in any event, which takes place when in 
a wart or mole, the fingers of which have been extended toward 
the surface and engaged in no malevolent work, some unknown 
agent suddenly reverses them and they reach out hungrily and 
malignantly into the subjacent tissue. So subtile is this change 
in these most simple, superficial little growths that Keen has 
gone so far as to counsel the removal of every wart and mole 
from one's body. If this be advised on the opinion of so high 
an authority, how great indeed must be the danger to which 
we are all exposed through these apparently harmless but very 
common growths. Furthermore, how much greater must be 
the danger of malignant degeneration taking place in the more 
complicated, more vascular and less freely observable tumors 
of the deeper parts. 

The appended figures represent an effort to show graphi- 



122 



BENIGN AND MALIGN CHARACTERISTICS. 



cally some of the major differences between an adenoma, a car- 
cinoma and a sarcoma. 

Fig. 20 



( ■V/»««5' ««**«* j 




Tlo-fc f»> +h'* 




3^ z^^ 



Fig. 27 




C./t. s. *« 

Fig. 28 



PROPHYLAXIS OF MALIGNANCY. 123 

Treatment of Carcinoma. The treatment of mammary 
carcinoma is determined absolutely by the distribution of the 
lymphatic drainage. The mortality rate from the radical opera- 
tion would be very much lower were it not for the unfortunate 
fact that the upper inner quadrant drains largely into the an- 
terior mediastinal glands and indirectly into the liver. Fortu- 
nately, however, the most extensive drainage is into the axil- 
lary and supra-clavicular groups. (See Fig. 25.) 

Thus it is that the position of the growth, particularly if 
it be a small one, determines the extent of the operative inter- 
vention. If, for example, the outer upper quadrant alone is in- 
volved, it may be deemed conservative to remove no more than 
the axillary glands with pectoralis major and minor. If, how- 
ever, as is too frequently the case, the growth when operated 
upon has invaded other quadrants of the breast, the supra-clavi- 
cular and in some cases even the anterior mediastinal glands 
are taken out. The first calls for a resection of the clavicle ; the 
second, for a resection of a portion of the sternum. The immedi- 
ate mortality of the operation is of course higher if the medias- 
tinal glands are attacked, but the chances of permanent cure, if 
the patient survive the operation, are enhanced. 

Prophylactic after-Treatment of Malignancy* 

This is a convenient point at which to consider the after 
treatment of all forms of malignant disease after they have 
been removed. The argument in general is this, that if certain 
agents about to be described are curative, as they have posi- 
tively been shown to be, of malignant growths, when superfi- 
cially situated may these agents not have a protective power in 
preventing the secondary development of malignancy after the 
tumors have been removed by the knife? It is accordingly the 
custom of some surgeons to treat their cases according to the 
terms of this argument. Some of the treatments referred to 
are : 

(1) The X-Ray. Both the curative and prophylactic power 
of this agent are generally recognized. The chief danger and 
difficulty has been the indiscriminate use of the rays by ignor- 
ant or unscrupulous operators. Such men yield to the tempta- 
tion to advocate radio-active treatment in the case of deep> 
growths, where the knife only is indicated. 



124 PROPHYLAXIS. 

(2) Finsen's Light. This was originally obtained by con- 
centrating the sun's rays through huge water glass lenses, the 
circulation of the water cooling the rays sufficiently to prevent 
their burning. It is now obtained chiefly from electric lights. 
Action depends on the unknown power of the violet and ultra- 
violet portions of the light. The work done by these rays is 
accomplished by vibrations which do not appear to us as color, 
because of their being situated ultra or beyond the violet side 
of the spectrum. They are too rapid for sight-perception. The 
chief function of the Finsen rays probably is in the treatment 
of Lupus. 

(3) Static Spray. This is simply the discharge from a 
powerful static machine applied to the part from a metal point. 
The erythema produced is similar to that of the X, and the 
Finsen Rays, but the curative properties are more limited. 

(4) Radium. This remarkable element possesses curative 
powers similar to those of the X Ray. They are stated by 
Abbe to be ten times less potent. It has, in addition to its 
therapeutic properties the remarkable ability to retard develop- 
mental processes. Abbe has shown that seeds, if exposed to 
radium radiations, are retarded in their growth proportionately 
to the time of exposure, and he has further demonstrated that 
meal worms, which ordinarily complete their cycle of develop- 
ment in about three months, if exposed to radium, remain meal 
worms ; refusing for an indefinite period to manufacture their 
cocoons: 

(5) Starvation. This treatment has been elaborately 
worked out by Dawbarn, and he has conclusively shown that 
in certain forms of sarcoma it is of distinct value and possibly 
so in the case of other malignant growths. The principle is to 
cut off as much nutrition as possible without causing the 
healthy parts to slough. Its most favorite site for employment 
is after the removal of sarcomatous growths from the region of 
the antrum or lower face. The technic consists not in ligation 
but in actual excision of the great bulk of the arterial and ven- 
'ous supply. 

The treatment then of malignant disease as exemplified in 
the breast, consists of early removal, followed by prophylactic 
treatment. This may be by prolonged exposure to Radio-activ- 
ity or by Starvation. 



CHAPTER XL 
STOMACH AND GUT. 



^ranches ft, 



~3Ta.77Ches ~?b 
Card,* 




-^ 



Fig. 29 
CELIAC AXIS. 



This drawing represents the stomach as a transparent body through 
which can be seen the pancreas and its arteries. To draw the 
Celiac Axis draw the lines 1, 2 and 3 (see small cut to right and 
below the main one.) Then join 1 to 3 and 2 to 3 in the manner 
shown. Subdivide the terminations of the lines 1, 2 and 3 and 
compare the result with the large sketch. 



126 GROSS PATHOLOGY OF ULCER. 

It is Utopian to look for the last days of proprietary diges- 
tants, but it is conservative to say that in future there will be 
more stomach lesions treated by the knife than by purgative 
pills and predigesting powders. 

We eat well but not wisely hence the stomach has many 
minor woes. Aside from these, the most interesting and most 
vitally important, because of its relation to carcinoma, is 

GASTRIC ULCER. 

The etiology of the condition is unknown, but it probably 
has much to do with repeated traumata of the mucosa. The 
pathology presents characteristic phenomena. The ulcer is ty- 
pically, a punched out area in the mucous membrane which 
may sometimes be seen through the serosa as a whitish region. 
It is white, partly because of anemia — the nutrient vessel which 
can usually be found leading to the center of the ulcerated re- 
gion, is very often thrombosed or plugged — partly because of 
the formation of scar tissue, which is here made with unusual 
rapidity. 

W. J. Mayo states that probably fifty per cent, of cases of 
gastric ulceration are complicated by a similar duodenal lesion. 
Until quite recently duodenal ulcers were supposed to have a 
rather constant relation to burns and other skin lesions. The 
ulcer bearing area of the stomach is rather strictly (80 per 
cent.) localized on the posterior gastric surface, near the py- 
lorus ; the ulcer bearing region of the duodenum is limited to 
the first portion of that gut. It would therefore seem that there 
is some physiologic or anatomic factor which renders this four 
or five inches of what is practically a funnel particularly prone 
to ulceration. This, though ignorance of its true cause, must 
at present be termed spontaneous. 

There are other regions of the alimentary canal which are 
prone to ulceration, but these ulcers are of a distinctly different 
type, tubercular, typhoid and the like. There is no other region 
in the entire gut so liable to idiopathic ulceration as this short 
pyloric funnel. Before attempting to give any differential 
tables, it should be stated that a positive diagnosis in most 
lesions of the abdomen is possible only after exploratory in- 
cision and often not even then. On account of the juxtaposi- 



DUODENAL RELATIONS. 

<f»7P 9>*cfa-t- fa****** J**e 



iTKhet Aa-nt 



127 




■from T^yJort/s +o 

A/ecK. 0/ gun Btaat/tr 

BthmtC 

Ut.T>a. ~Po>f at 
9<*>+r.'Duudcf,c,7 d^f 



ftt/ocu fo; 



Fig. 30 
Relations of 1st part of Duodenum. 




V*n» Cava 

/?e»u7 Vctsc/r 
Uy+ar. 



Oc/Ycr S/c/ r 

Colo* 



Fig. 31 
Relations of 2nd part of Duodenum. 



128 



ULCER-BE ARIXG PYLORIC FUNNEL. 



I'Tmr.tom, 




vpptr [harder- 

?puf Lumbar. 



Covered "> -fr*mr *>y 

L t fr ^cu.f of frx. senary 



+* & 



■nt,J)*r. 



Fig. 32 
Relations of 4th part of Duodenum. 

tion of the gall bladder and its ducts to the duodenum and the 
stomach, lesions of these parts are apt to be confounded. 

Duodenal Ulcer because of these studies is coming into 
great prominence and the time probably is not distant, when, 
instead of reference being made to gastric or to duodenal ulcer, 
separate and apart from each other, efforts will centre on the 
demonstration of ulceration in the ulcer bearing pyloric funnel 
already referred to. Nevertheless, it is still stated that duode- 
nal ulcers have certain distinguishing characteristics. They 
are so vague, however, that Brewer states it to be impossible 
to differentiate the pyloric ulcer. Xo attempt will therefore 
be made to do it. 

Duodenal ulcers are said to occur in two per cent, of bad 
burns. This percentage was much higher in the pre-antiseptic 
days. They may also follow frost bite, erysipelas, pemphygus, 
septicemia and eczema. Their possible exciting etiology may 
be (i) Septic emboli; (2) Destruction of blood cells; (3) Ab- 
sorption of toxins from cellular degeneration ; (4) Nerve irri- 
tation. They may appear from four to six days after the burn 
or injury. 



DIFFERENTIAL BETWEEN 



129 



Carcinoma of 
Pylorus. 



Ulcer of Pyloric 
Funnel. 



Gall Stones of 
Common Duct. 



Chronic 
Cholecystitis. 



History of Tumor. 



Absent in early 
stage. 



Onset always 
slow. Progress- 
ively worse. 
Cachexia. 



Gastric ulcer or 
primary carci- 
noma elsewhere 



Over forty. 



Male. 



Rarely present. 



Absent. 



History of Disease. 



Onset more rapid. 
Characterized by 
exacerbations. 



Onset abrupt. 
Acute exacer- 
bations. 



Previous Disease. 
Chlorosis. Typhoid fever. 

Age. 

Mid-adult life. 
Sex. 

Female. 



Under forty. 



Female. 



Frequent. 



Onset slow. 
Chronic course 
with exacerba- 
tions. 



Chronic duodenit- 
is. 



Mid-adult life. 



Female. 



Occupation. 



Negati 



Change from an 
active out-door 
to a sedentary 
one, as seen in 
the case of emi- 
grant servant 
girls. 



Commonly ascrib- 
ed to indolence 
and over-eating 
but by a recent 
continental 
writer thought 
to be due to the 
opposite. 



Pain. 



2 to 3 hours after 
eating. Charac- 
teristic. Grind- 
ing. Rarely be- 
gins at night. 



Chronic dyspepsia 
Progressive 
weakness. 



Cha racteristic. 
Acute. Relation 
to eating, direct 
and immediate. 
Rarely begins 
at night. 



Remittent. Se- 
vere. Shoulder. 
No relation to 
eating. Typic- 
ally T begins at 
night. 



Disability. 



Intermittent dys- 
pepsia. Acid 
eructations. 



Low grade chron- 
ic d y s p e p sia, 

frequent. 



Negative. 



Intermittent. Less 
severe. Only 
with exa cerba- 
tions. Usually 
begins at night. 



Dyspepsia, 
mittent. 
ous". 



inter - 
"Bili- 



130 



DIFFERENTIAL BETWEEN.— Continued. 



Carcinoma of 
Pylorus. 



Ulcer of Pyloricj Gall Stones of 
Funnel. Common Duct. 



Chronic 
Cholecystitis. 



Negative. 



Uncommon, ex- 
cept in exten- 
sive involve- 
ment produ- 
cing pressure on 
the duct. 



Occasional ' 'tarry 
movements. 



Bowels. 

Constipation. I 
May be "clay" 
movements. 



Constipated. 



Normal. 



Absent. 



Jaundice 

A b s en t , except 
under similar 
conditions, 
which are rarer 
than in carcino- 
ma. 



A very character-. Frequent during 
istic symptom. exacerbations. 



Temperature. 



Variable. 



Characteristically 
intermit tent. 
Chills and 
sweats, 98 to 103 re ^ ular: 98 " 10d - 



Present during ex- 
acerbations. Ir- 



NERVOUS SYMPTOMS. 

Delirium. 



Absent. 



Not infrequent. 



Occasionally dur- 
ing exarcerba- 
tions. 



Absent. 



Absent. 



Paresthesiae. 



Itching of skin. ; Occasional itching- 



Negatr 



Negative. 



Urine. 



High-colored andi Same during ex- 



stains linen. 



acerbations. 



Evidence of ca- 
chexia. 



GENERAL PHYSICAL. 
Inspection. 



Pallor and pro- y u 
nouned anemia. 



May be yellow. 



Possible tumor. 



LOCAL PHYSICAL. 
Inspection. 

P mQr bly U ° tU " No tumor - 



Probable tumor.. 



131 



DIFFERENTIAL BETWEEN— Continued. 



Carcinoma of 
Pylorus. 



Ulcer of Pyloric 
Funnel. 



Gall Stones of 
Common Duct. 



Chronic 
Cholecystitis. 



Palpation. 



May feel tumor on| 
deep respiration' 
Tenderness nearr ame - 
mid-line. 



No tumor. Ten- 
derness at "Rob- 
son's" point. 



BLOOD. 

Leucocytosis. 



About 60%, 8,000. 
About 20%, 10- 
000 to 12,000. 
About 20%, 20- 
000 to 40,000. 
(Cabot) 



Depends on de- 
gree of cachexia 



Very frequent. 



Undigested food 
particles. 



About 20%,, 10,000 
to 12,000. 



Usually absent. 



Hemoglobin. 

One-half have less 
than 50% (Cab- 70 to 80% 
ot) 

URINE. 

Indican. 



Absent. 



Evidences 
blood. 



Absent. 



Feces. 



of I Absence of color- 
ing matter. 



Tumor usually atl 
pylorus or on 
lesser curvature 



Exploratory Incision. 
! Ulcer 50% in first 



part of duode- 
num remainder 
on posterior py- 
loro-gastric wall 



Stone often lodg- 
ed im ampulla 
of Vater. 



Tumor. 



May be marked 
during exacer- 
bation. 



70 to 80%> 



Absent. 



Coloring matter 
may be absent 
during exacer- 
bation. 



Dilated or atro- 
phied diseased 
gall-bladder. 



As in the case of the breast, probably the most interesting 
as well as the most vital, question in the surgery of the stomach 
is the problem which bears on the relation of a carcinoma to 
a gastric ulcer. In the breast it is frequently a benign tumor, 
that is to say, a growth not traumatic in origin, which under- 



132 SURGERY OF THE STOMACH. 

goes the degenerative malignant change. There are, however, 
many examples to show that the chronic irritation arising from 
mild, low grade infection, as often occurs in frequently fissured 
nipples and similar apparently insignificant lesions have a very 
important bearing upon malignant degeneration. In the 
stomach, benign tumors are rare, the source of malignancy tak- 
ing its origin almost entirely in the bed of old inflammatory 
lesions (ulcers). Chronic irritation then plays a most import- 
ant part in the stomach and this is further exemplified by the 
very fact that carcinoma of the stomach is much more frequent 
in men than in women. Men eat too much and eat too indiges- 
table substances. There is probably some connection between 
these two facts. 

Pain, dyspepsia, acid eructations, loss of weight, vomiting ; 
these are some of the symptoms which, singly or in combina- 
tion, bring the patient to the surgeon's observation. Every one 
of these sufferers has been subjected to all conceivable and to 
many inconceivable forms of treatment. They have been 
bathed in boiling and sprayed in ice cold water. They have, 
for hours at a time, knelt with their buttocks on high and their 
heads on low. They have suffered great iron balls to be rolled 
and tumbled over their tender belly walls. They have con- 
sumed thousands of dollars worth of drugs. They are at last 
coming to their own ! , 

The symptoms above referred to arise directly from the 
inflammation of nerve terminations as in the case of ulcer, or 
indirectly, as in the case of carcinoma and other diseases which 
produce pyloric obstruction, through a stretching of the parts 
and a necessity arising for them to do work for which they 
were not built. 

Surgery applies to the stomach the simple common sense 
methods that she utilizes elsewhere. She puts inflated parts 
at rest and establishes drainage. 

The surgery of the stomach is easy to understand and 
there can be no possible misconception about it if these two 
simple facts are remembered. 

What, for example, is the surgical treatment of ulcer of 
the stomach? Put the part at rest. Since the ulcer is usually 
located near the pylorus, if this funnel be put out of use, the 



TWINE-TRIANGULAR STITCH. 



13$ 



ulcer will heal. Consequently one of the most frequently em- 
ployed technics for the treatment of ulcer (Robson, Moynihan 
and others) is Gastro-enterostomy. 




Fig. 33 

Gastro-enterostomy made by the twine-triangular stitch. 
(Columbia Surgical Laboratory) 

This deservedly popular operation serves the second in- 
dication, viz. — that of establishing drainage just as admirably 
as it does the first. For this reason, it is employed in the treat- 
ment (palliative in the case of carcinoma, as are many surgical 
operations) of Pyloric stenosis. All the great and little evils 
from which a case of pyloric carcinoma suffers are done away 
with as though by magic through the execution of gastro-en- 
terostomy. The technic is simple. The jejunum and the 
stomach may be brought into communication by ligature and 
section : by Murphy Button ; by the the Twine-triangular stitch 
(see Report from Columbia Surgical Laboratory, 1904.) 



134 



REST AND DRAINAGE. 



Other methods are used for the relief of these lesions of 
the stomach, but they must always be based on the simple 
proposition of rest and drainage. Finney's pyloroplasty is ac- 
knowledged to be the best of these. See Brewer's text book. 




tsnuirj 



Fig. 34 
POSTERIOR RELATIONS OF STOMACH. 

The Greater Curvature has been lifted upward and to the left. 
This accounts for distorted (diagrammatic) shape of the stom- 
ach. Note that head of pancreas is not in relation. 



Gastrostomy. — Occasionally because of impassible stric- 
ture of the esophagus, a permanent opening has to be made in 
the stomach through which the patient may be fed. A similar 



SURGERY OF TYPHOID ULCERS. 135 

opening occasionally has to be made in the colon through 
which the patient may in case of permanent obstruction or des- 
truction of the rectum evacuate his bowels. There is no truer 
example than that found in a study of Gastrostomy and Colos- 
tomy, of the axiom that to succeed, an operation must imitate 
nature as closely as possible. She has passed through the ab- 
dominal wall a tube which for all practical purposes is similar 
to the rubber tube used in gastrostomy. It is the spermatic 
cord. It traverses the abdominal wall by an intermuscular 
course. The length of the canal is constant and the relation of 
the muscles to it is always the same. The most effectual means 
of establishing a permanent opening into the stomach or the 
colon is based upon the principle that it should be made as 
nearly like the inguinal canal as possible. That is all there is to 
these so called valve or telescoping operations ; they simply im- 
itate nature. 

Surgical treatment of typhoid ulcers. As about 8,000 peo- 
ple a year die in the United States alone of perforation or 
hemorrhage from typhoid fever, it is obviously an important 
matter to reach a means of treating this vital condition surgi- 
cally. 

In a very high percentage of cases the lesion takes place 
within the last 24 inches of the ilium. The symptoms of per- 
foration classically are pain, sudden and sharp attended by col- 
lapse, but unfortunately there are too few cases that follow the 
classical picture. It has been suggested as a palliative method 
that some coagulable jelly-like material should be injected into 
the gut somewhat as engineers sometimes put oatmeal into a 
leaking boiler. Increased assurance in the opening of the abdo- 
men under local anesthesia will undoubtedly do a great deal to 
help this rather discouraging situation. 

APPENDICITIS. 

There is not an unmixed joy in being a new woman. She 
has appendicitis just about as often as her brother. Formerly 
he had it four times to her once, but now that she bicycles cen- 
turies, plays golf and basket ball, she has in more than one 
sense become his equal. This seems to be rather convin- 



136 TOXICITY RAISED BY PRESSURE. 

cing that violent exercise has a good deal to do with the et- 
iology of appendicitis. 

It has been noticed that prolonged and violent bicycle rid- 
ing, for instance, has in an unusual number of cases been fol- 
lowed by an acute attack. This suggests that overaction of the 
psoas in the case of an appendix which droops down into the 
pelvis by bringing it thousands of times in harsh contact with 
the pelvic brim gives the disease its first start. 

The suggestion that women are usually so less liable to 
appendicitis than men because of the greater blood supply to 
the organ in the female has probably been shown to be erron- 
eous by the facts already cited. Vascularity it is now believed 
has little or nothing to do with the etiology. 

Stricture of the organ is usually present. It is easy to con- 
ceive that stricture here will act just as it does elsewhere, viz. — 
for example in the urethra. Some variation in temperature, 
some unusual germ activity, or some unknown conditions may 
be supposed to start the elements of a simple exudative inflam- 
mation. It is known that the bacillus coli is practically ubiqui- 
tous. It has been found in the gut of birds killed far out at 
sea. It is therefore in most cases a resident of the appendix 
throughout the length of its lumen. What happens after the 
inflammation begins? The stricture swells and distal to it there 
is shut in by the obliteration of the lumen, a little lake-like area 
which, if not already full of fluid, rapidly fills after its closure. 
The fluid is rich in food stuffs and it is at 98.6, the temperature 
most favorable for the development of pathogenic germs. It is 
inevitable that the colon bacilli propagate. Among the prod- 
ucts of their metabolism are gases. These together with other 
metabolic outputs are created more rapidly than the dilated 
and engorged vessels of the part can carry away. Pressure in 
the little lake results. The effect of growing germs under pres- 
sure is a very constant one. Germs producing substances poi- 
sonous to man, when put under pressure are more dangerous 
than otherwise. Germs which, like the colon bacillus, are harm- 
less to us under the usual conditions of pressure, become viru- 
lently poisonous when this is augmented. Thus is explained 
the great virulence and the remarkable local destructive power 
of the fluids contained within these appendicular sacs. 



DIFFERENTIAL BETWEEN 



13? 



Appendicitis. 



Right Sided Sal- 
pingitis. 



Right Ruptured 
Ectopic. 



Acute 
Cholangitis. 



History of Tumor. 



Very frequent. Frequent. 



Absent. 



Onset slow, belly- 
ache. 



Constipation and 
previous at- 
tacks. 



Male, 3 to 1. 



History of Disease. 

Onset fulminat- 
ing ; very severe 



Onset slow ; pelvic 
cramps. 



pelvic cramps. 
Previous Disease. 



Absent. 



Onset acute ; belly 
ache. 



Gonorrhea. 



Often previous 
pregnancies. 



Female. 



Sex. 

Female. 
Social State. 



Typhoid. 



More frequent in. 
female. 



Single. 



Begins at navel 
and radiates to 
Mc Burney's 
point. 



Very frequent. 



Absent. 



Prostitutes. 



Married. 



Pain. 



Begins in pelvis. 
May be referred 
down right leg. 



Most severe of all. 
Localized in pel- 
vis or referred. 



Negative. 



Severe. Often re- 
ferred to Rob- 
son's point. 



Infrequent 



Absent. 



101 to 103. 



Full, 120 usually 
regular. 



101 to 103. 



Same. 



Vomiting. 

Very rare. 
Jaundice. 
Absent. 
Temperature. 

i.5 to 99. 
Pulse. 



Weak, 140 to 160, 

irregular defi- 
cient, short and 
compressible. 



Frequent. 



Frequent. 



101 to 103. 



Full 120 regular. 



188 



DIFFERENTIAL BETWEEN— Continued. 



Appendiciti: 



Right Sided Sal- 
. pingitis. 



Right Ruptured 
Ectopic. 



Acute 
Cholangitis. 



GENERAL PHYSICAL. 
Inspection. 



Flushed, anxious 
asthenic, febrile 
look. 



Often tumor. 



'Board like" ab- 
domen. Vaginal 
negative. Press- 
ure pain at Mc- 
Burney's point. 



Very limited area 
of flatness. 



8,000 to 11,000 
means (A) mild 
case. (B) very 
severe case. (C) 
Abscess walled 
off. Increasing 
1 e u c o c y t osis 
may be only 
evidence of dis- 
ease. (Cabot) 
20,000 to 80,000 
not uncommon. 



0.9 



Abscess found at 
caput coli. 



Same but often to 
a less degree. 



Pale, sweaty, pros- 
trated, asthenic 
look. 



LOCAL PHYSICAL. 

Inspection. 



Possibly tumor. 



Absent. 



Palpation. 



Rigid right side 
but less marked 
than in appendi- 
citis. Vaginal 
tumor. Pain in 
lower right a b- 
dominal seg- 
ment. 



Diffuse moderate 
rigidity. Vagi- 
nal; boggy, se- 
vere pressure 
pain. Abdomen 
filled with fluid. 



Often negative. 



Percussion. 

Flatness in flanks 
disappears on 
turning patient 
on side. 



Same as salpin- 
gitis. 



Absent. 



Moderate rigidity- 
tenderness i n 
upper right ab- 
dominal seg- 
ment. 



Limited flatness 
tip of ninth rib. 



BLOOD. 

Leucocyte Count 



Same as appendi- 
citis, but less 
marked. 



16,000 to 18,000. 



Color Index. 
0.9 0.5 to 0.6 

Exploratory Incision. 
of right 



20,000 to 80,000. 



Abscess 
tube. 



Free blood in 
periteneal cav- 
ity. 



0.9 



Dilated gall blad- 
der. 



OCHSNER'S TREATMENT. 139 

The blood has come to be a most efficient aid in diagnosing 
appendicitis and in differentiating it from certain other condi- 
tions. It is readily seen that the appendix, the tube and the 
gall bladder are organs, which although occupying different 
positions in the abdominal cavity, have nevertheless almost 
identical anatomical structure. It is probable that no disease 
develops either in the tube or in the gall bladder except by 
stricture formation. As in the case of the appendix drainage 
is interfered with and the distal parts of the organ become shut 
off so as to form practically a culture tube for germs. These 
will not make trouble so long as there is no pressure and in 
the presence of unrestricted circulation. In the face of such 
resemblances it is natural that the blood should not give much 
differential information between these three conditions. It 
should be remembered that it is not so much a question of the 
amount of pus, but the degree of tension under which it is pent 
up which determines the amount of leucocytosis. A gum boil 
under pressure will often give a count of 20,000. 

Whereas the presence of leucocytosis is, in many cases 
very variable, there is a list of diseases which are definitely and 
constantly characterized by its absence. They are as follows: 
(Cabot) (1) Typhoid, (2) Malaria, (3) Grip, (4) Measles, (5) 
Rotheln, (6) Mumps, (7) Cystitis, (8) Tuberculosis — all forms, 
including miliary and tuberclous peritonitis. 

In typhoid and miliary tuberculosis the leucocytes are 
often diminished. 

Leucopenia is a diminution of the number of white cells. 
It is present not alone in tuberculosis and typhoid, but to a less 
degree during stages of most of those infectious diseases which 
are not characterized by leucocytosis. 

The treatment of appendicitis is the most difficult of the 
usual problems presented to the surgeon. There are two dis- 
tinct schools, the one advocates operating when the diagnosis 
is made; the other, except in chosen cases, advises subjecting 
the patient to a special form of treatment prior to operation. 

This is known as Ochsner's Treatment. It consists in giv- 
ing the patient absolutely nothing by mouth, not even water ; 
in administering enough morphine to relieve pain ; in never 
giving any form of purgation whatsoever. The object is to 



140 INVAGINATION OF APPENDIX. 

apply the surgical principle of putting the inflamed part at rest 
and of allowing nature to "wall off" the abscess. It is said that 
so successful has this treatment been in some cases that ab- 
scess formation has even been prevented by it. Its use is justi- 
fied, however, as distinctly insisted upon by Ochsner, only 
after a thorough understanding of its contra-indications. 

Probably the most popular method of removing the ap- 
pendix is by that first suggested by Dawbarn. He has always 
thought that the hole left after removal of the organ is exactly 
similar to that created by a bullet and should in all common 
sens,e be subjected to similar treatment. It is therefore more 
surgical to throw a purse string suture around the stump prior 
to cutting off the organ and to invert it into the gut by trac- 
tion than to use pure carbolic or the actual cautery to destroy 
the mucous membrane that the parts may heal. 

THE COLON. 

The colon has recently become the subject of special sur- 
gical interest, because of the necessity of treating some of the 
chronic diarrheas and dysenteries (particularly the amebic 
form) by surgical intervention. These forms of colon inflam- 
mation were first brought prominently into notice by soldiers 
who came home from Cuba and the Philippines. No form of 
internal medication served to relieve the condition and many 
of them died. Thirty to forty movements a day were not un- 
common, and that, in spite of the most active medicinal treat- 
ment. In these desperate cases it was suggested to do a right 
sided colostomy with adequate spur-formation. 

The advantage of the spur is that it turns every particle 
of fecal material on to the surface and thus allows the distal 
portion of the gut to be sterilized and kept clean. Its disadvan- 
tage is that, unless established by some procedure as recom- 
mended by Bodine, in which case it can be broken through with 
a Paquelin cautery, it necessitates a secondary and often a 
very severe operation. The spur then is indicated in all con- 
ditions where radical treatment has to be applied distally to it. 
It is not indicated in those cases where an opening is made, as 
for instance in strangulated hernia, simply for the relief of in- 



"MARSUPIALIZATION" 141 

tra-enteric pressure. The importance of the inter-muscular 
operation in this connection has already been discussed. 

Weir, when the pertinence of the surgical treatment of the 
colon became manifest, suggested with customary ingenious- 
ness, that instead of bringing the colon to the surface and thus 
doing an ordinary colostomy, the appendix should be utilized 
to connect the colon with the outer world. Twelve to twenty- 
four hours after the appendix had been made fast in the ab- 
dominal wall, its tip was to be nipped off and disinfecting irri- 
gation fluids squirted through it into the colon and rectum. 
This technic will not shunt the gut contents to the surface as 
in the case of the spur operation, but for amebic dysentery it 
serves the purpose equally well. When the enteritis is cured 
presto ! a hot iron shall be thrust into the lumen of the appen- 
dix, thus closing the colostomy and incidentally doing away 
with the appendix. This method has been widely used and has 
been called Weir's Marsupialization. (The marsupial has a 
pouch in which its young are carried. The term and principle 
are sometimes used in surgery.) 

THE RECTUM. 

Fissure, Fistula and Hemorrhoids are the three most com- 
mon lesions of the rectum. They cause untold suffering and 
unless relieved are the very type of chronic injury which is lia- 
ble to malignant degeneration. It is therefore of very great 
importance, not only for the relief of immediate pain and dis- 
comfort which they cause, but for the more far reaching dan- 
ger to which they subject the patient, that they should be in- 
telligently treated. One of the most favorite differentials is 
between these three ills. It will be noted that the most im- 
portant differential point is the time of occurrence and the 
character of the pain. It is usually possible to make a differ- 
ential on the history alone and this is often convenient. 



142 



DIFFERENTIAL BETWEEN 



Fissure in Ano. 



Fistula in Ano. 



Hemorrhoids. 



Early 
Malignancy. 



History of Tumor. 



Absent. 



Onset sudden. 



Negative. 



Absent. 



Present. 



Disease. 



Onset slow. 



Onset slow 



Previous Operation. 



Not infrequent. 



Injections. 



Pain. 



Inter mitten t.j 
Sudden, knife- 
like. Last only Discomfort only. 
10 seconds after 
bowels move. 



Remittent. 
Heavy, drag- 
ging. Severe for 
two hours after 
bowels move. 



Disability. 



Afraid to have a Cannot hold gas 
movement. and fluid. 



Weak from loss 
of blood. 



Present. 



Onset very slow. 



May follow hem- 
orrhoid removal 



Not characteristic 



Weak from be- 
ginning cachexia. 



INTESTINAL OBSTRUCTION. 



This is probably the most frequently asked of all hospital 
questions. It is therefore worth while to condense it into as 
short a space as possible. It is 



Acute: Chronic. 

Causes Acute. 

Intussusception (acute). Bands. Volvulus. Foreign bod- 
ies, gall stones and enteroliths. Internal hernia 
(Meckels diverticulum and abdominal fossae.) 

Causes Chronic. 

Impacted feces, strictures (benign and malignant). 
Intussusception (chronic.) 



INTESTINAL OBSTRUCTION. 145. 

Pathology Acute. 

Above obstruction equals gas. 
Below obstruction equals empty. 

At obstruction equals ulceration, perforation, periton-- 
itis. 

Pathology of Chronic. 

In and above equals hypertrophy. 
Below equals empty and atrophy. 
At obstruction equals same as acute. 

Symptoms of Acute. 

Same as acute strangulated hernia. 

Pain, sudden and diffuse. 

Collapse. 

Tenderness, little or none. 

X7 ... ( High — early, billious. 
Vomiting T 5 * j. 1 1 
& / Low — late, fecal. 

Constipation absolute (obstipation.) 

Tympanites. 

Hiccough. 

Peristalsis (if walls thin). 

Increasing dysuresia. 

Pulse rapid and feeble. 

Temperature and tenderness from peritonitis only. 

Great prostration and emaciation if last long enough. 

DIFFERENTIAL. 
Does Obstuction Exist? 

History of Hernia in unusual places. 

History of feces or foreign body. 

Save and inspect urine, feces and vomit. 

Examine for concretion, bile, bloody and mucous dis-~ 
charge. 

Examine for external hernia ; uneven abdominal disten- 
tion. 

Rectal examination for invagination, feces or stricture. 

Palpate and percuss abdomen for tumor, tenderness, 
tympanites. (Do not put hand sound or measured, 
enema in rectum). 



144 INTESTINAL OBSTRUCTION. 

Differentiate from Gastro-enteritis. 
Early state Meningitis. 
Biliary and renal colic. 
Peritonitis. 
Appendicitis. 
Pyosalpinx. 
Gastric ulcer. 
Acute Cholecystitis. 

Where is Obstruction? 
SMALL GUT. 
Obstruction High — Symptoms. 
Violent onset. 
Early collapse. 

Early and persistent vomiting, bilious rarely fecal. 
Tympanites absent or limited to epigastrium. 
More or less dysuresia. 

LARGE GUT. 
Obstruction Low — Symptoms. 
Onset slow and mild. 
Increase in violence of symptoms. 
Collapse late (except in volvulus). 
Tympanites first in colon, then 
Vomiting. 
Abdomen more bulging on side than center. 

Obstruction in Jejunum or Ilium — Symptoms. 

Eliminate duodenum, colon and rectum. 

Course moderately rapid. 

Vomiting fairly early. 

Tympanites later. 

Abdomen more distended at center than at side. 

What is Obstruction? 
Acute Invagination — Symptoms. 
Child. 

Elongate tumor on left side felt via anus. 
Tenesmus and bloody discharge. 
Local pain. 
Sudden onset. 



INTESTINAL OBSTRUCTION. 145 

Bands — Symptoms. 

History of previous peritonitis. 
Tuberculosis elsewhere. 
Local pain. 

Volvulus — Symptoms. 

Old males. * 

Localized tympanites. 

tumor. 

pain. 
Usually left iliac fossa in sigmoid. Note. Worst of all. 

Foreign Bodies — Symptoms. 
History false teeth. 
Biliary colic. 
Constipation. 
Palpation. 

Internal Hernia — Symptoms. 

Local pain and tenderness over the abdominal fossae. 

Chronic Obstruction — Symptoms. 

Includes symptoms of impacted feces. 
Tumefaction in colon. 
Rectal examination for feces. 
Old people. 
Young girls. 

Stricture — Symptoms. 

History of dysentery. 

Symptoms of visceral malignancy. 

Old people. 

Chronic Invagination — Symptoms. 
History stricture or tumor. 
Tumefied colon, not compressible. 
Mucous and bloody stools. 
Tenesmus. 



146 INTESTINAL OBSTUCTION. 

Treatment of all Forms. 
Lavage. J 

Opii. 

No cathartics. 
Enemata. 
Spoon out rectum. 
No tubage of colon. 
No puncture of intestine. 
Uniform and continuous abdominal pressure. 
Laparotomy. 
Enterotomy. 
Enterectomy. 

Enterrorhaphy and anastomosis. 
Colostomy. 



CHAPTER XII. 



LIVER, SPLEEN AND PANCREAS. 



The surgery of the liver centers on the relief of disorders 
of its secretory passages. So called gall stone colic is probably 
(Brewer) not due to gall stones at all, but to spasmodic con- 
traction of the inflamed ducts pressing on the nerves. 

The Gall Bladder is directly connected with the surface of 
the body and so is the liver. They are therefore, in common 
with other organs situated upon the surface of the body, sub- 
ject, first, to superficial invasions by germs and animal paras- 
ites, and second to the particular form of malignant degenera- 
tion to which the surface is liable, viz. — Carcinoma. Bacterio- 
logically speaking, the inner and outer body surfaces are dirty. 
As the liver and pancreas are the most deeply situated of these 
superficial organs, it is appropriate here to show a diagram 
which proves this somewhat surprising hypothesis. 

It is simply a question of remembering 
that there are two surfaces, an outer and an 
inner, and these organs together with the 
parotid gland, the hepatic gland and certain 
others, are located on the inner surface. 

The Liver is occasionally the seat of ab- 
scess. It has to be differentiated from sub- 
phrenic abscess, which is a collection of pus 
immediately beneath the diaphram, due usu- 
ally to gastric ulcer; from costo-phrenic ab- 
scess, which is a collection of pus in the 
costo-phrenic sinus, a sketch of which is 
shown in Chapter X, and from empyema. 
Note that an important factor in this differ- 
ential is the effect of respiration upon the 
discharge of the pus after exploratory incision. 




Fig. 35 

Figure of barrel show- 
ing inner and outer 
surface. 



148 



DIFFERENTIAL BETWEEN 



Liver Abscess. 



Sub -Phrenic Ab- 
scess. 



Costo-Phrenic 
Abscess. 



Empyema. 



Previous Disease. 



Duct, cystic or 
duodenal infec- 
tions. 



Amebae. 



Gastro - duodenal 
ulceration. 



Thoracic 
tions. 



infec- Pneumonia or 
Pleurisy. 



Exploratory Puncture. 

| P n e u m o coccus ! 



Pyogenic 
isms. 



T. B. ; Strepto- 
or S t a p h y 1 o- 
coccus. 



Same. 



Incision. 



Pus may flow 
faster during in- 
spiration (dia-!Same. 
phragm goes! 
down.) 



Pus may flow 
faster during L, 
expiration (dia-i 
phragm goes up) I 



The liver, on account of being on the surface, is occasion- 
ally, as already said, the subject of parasitic invasion. Liver 
abscess may be grossly divided according to the three zones 
in which it is most prone to occur. 

Frigid Zone or Echinococcus Cyst. The Echinococcus as it 
occurs in man is the asexual form of the tenia echinococcus of 
the dog. It is a moderately small tape worm. 

The Laplanders live in such intimate relations with their 
dogs that their food habitually becomes contaminated with the 
animal's feces. Consequently in Lapland and throughout the re- 
gion where dogs are largely used for transportation purposes^ 
man is very frequently the subject of echinococcus infection. 

The cyst formed by this parasite is characterized by multilo- 
cular formation, having daughter and grand-daughter cysts. 

Torrid Zone or Ameba Cyst. In the Torrid Zone, the 
ameba of dysentery abounds. Not infrequently it finds its way 
from the gut into the liver. The result is the amebic or dysen- 
teric abscess characterized by being single and by a rather 
strict localization to the southern climes. (See Chapter XVI.'i 

Temperate Zone or Pyemic Cyst. The Temperate Zone is 
not exempt from its peculiar abscess. We do not live in close 



CLASSIFICATION OF CYSTS. 149 

communion with our dogs, or suffer from amebic invasion. 
Amebae are frail and require the bad hygiene and torrid heat 
of the tropics. We have with us, however, as steady compan- 
ions, many pyogenic bacteria. Any one of these may make 
the characteristic Temperate Zone or pyemic abscess. . 

These abscesses or cysts of the liver suggest a classification 
of cysts. Cysts may be conveniently divided into 

(i) Retention. 

(2) Distention. 

(3) Tubular. 

(4) Glandular. 

(5) Parasitic. 

(6) Dermoid. 

The only way to get hold of this classification is to apply it. 
It will be noted that a cyst is often to be described by using 
a combination of these terms. For example, it is either reten- 
tion-tubular or retention-glandular, as the case may be. Take 
a Glactiferous Cyst for instance. That is caused by pent up 
milk in the milk ducts. Xow the mammary gland secretes a 
fluid which is intended to come to the surface. Cysts of it are 
therefore retention cysts. This is because what was intended 
to come out, is retained. The Glactiferous Cyst therefore, be- 
cause the milk is retained in tubes, is a retention-tubular cyst. 
Distention cysts, on the other hand, occur in regions where 
the secretion is not intended to come to the surface, as for ex- 
ample in the case of a bursa. Cystic change in this is called 
bursitis. It is a distention cyst. These occur also in the duct- 
less glands, as in the ovary or thyroid. They may therefore, 
as in these two latter cases, be called distention-glandular cysts. 
A distention-tubular cyst obviously cannot well exist. The 
echinococcus cyst is an excellent example of the parasitic cyst, 
which is here meant to mean an animal parasite. 

Some of the more common animal parasites of man in 
addition to the echinococcus are described in Chapter XVI. 

SPLEEN. 

On account of the vascularity of this organ, practically all 
that can be done to it is puncture or removal. Puncture is con- 
fined to obtaining from it specimens of central blood in which 



150 



RELATIONS OF PANCREAS. 



certain forms of parasites, unwilling to circulate in the peri- 
pheral blood, are resident. 

Excision or Splenectomy, while a formidable operation, 
is the only possible chance for patients suffering from splenic 
pseudo-leukemia. Splenectomy is also the only possible means 
of treating idiopathic splenic enlargement. 

Banti's disease, a condition of splenic enlargement, asso- 
ciated with hepatic cirrhosis, is another condition for which 
splenectomy is undoubtedly indicated. Other conditions which 
may call for removal are: rupture, wandering spleen, cysts, 
tumors and malarial hypertrophy. 



PANCREAS. 



/ft/asf oj \7)uac/cnu7n 




LipcrroT files e 71 fct*. VC/h, 



Fig. 36 



WJ. 2*. 



RELATIONS OF PANCREAS. 

(Seen from the front) 



PANCREATITIS. 151 

Much of the recent surgery of the abdomen centers upon 
the pancreas. The diseases of this organ have a very intimate 
relation to those of the liver and bile duct. Acute pancreatitis, 
both hemorrhagic, suppurative and gangrenous, is one of the 
least understood abdominal lesions. It may arise from ordi- 
nary germ infection, just as in the case of other organs, but 
there is a rather constant relation of biliary duct disease to it, 
which makes it seem probable that in many cases, at least, this 
is a powerful predisposing, if not actually an indispensable 
cause. 

Acute hemorrhagic pancreatitis is characterized by the 
usual evidences of intra-abdominal inflammation ; rigidity, ten- 
derness, distention and very severe pain. On account of the 
depth of the organ a definite tumor rarely appears. The con- 
dition cannot be diagnosed except on exploratory incision. In 
its later stages it is differentiated by exclusion — because of the 
appearance of their characteristic symptoms — from perforated 
duodeno-pyloric ulcer ; from appendicitis ; from acute intestinal 
obstruction ; from peritonitis; from acute cholecystitis; from 
pyonephrosis. The difficulty, however, of waiting for differen- 
tial points to arise is that unless relieved in its early stages, 
acute hemorrhagic pancreatitis usually kills in a very few 
hours. The recognition then of acute hemorrhagic pancreatitis 
depends only upon exploratory incision. The moment the ab- 
domen is opened, white patches are seen throughout the omen- 
tum and in the mesentery. They vary from the size of a pin's 
head to large irregular masses. They are the so-called areas of 
fat necrosis. The origin of this fat necrosis is not yet under- 
stood but it is supposed by some to be due to the liberation in 
the abdominal civity of the fat splitting ferment of the pancreas. 
The objection, however, to this theory is that fat necrosis has 
been seen in these cases occuringin fatty areas where it seems 
improbable that the ferment could have reached it. The sub- 
ject is therefore subjudice. The gland when exposed is found 
to be spachelous and as the shock of removal would certainly 
kill the patient, all that can be done is to see that adequate 
drainage is established. 

Chronic pancreatitis or the development in the organ of 
dry productive inflammation, is an interesting and not infre- 



152 



AMPULLA OF VATER. 



quent disorder. Even more than the acute form it has a rela- 
tion to interference of the gall duct circulation. Opie has 
shown that in many cases there exists in the ampulla of Vater 
a gall stone which, too large to pass out through the papilla, 
is yet large enough to net within the ampulla as a ball valve. 

It is clear that when the ampulla is blocked, the bile must 
pass directly up through the pancreatic duct into the pancreas. 
The patency of the accessory ducts (Santorini) of the pan- 
creas are of obvious importance in safeguarding the individual 
from chronic pancreatitis arising in this way. If present they 
maintain adequate pancreatic drainage. 

DIFFERENTIAL BETWEEN 



Chronic Pancrea- 
titis. 



Chronic Gastro- 
Duodenal Ul- 
ceration. 



Chronic Chole- 
cystitis. 



Liver Carcinoma 



History of Tumor. 



Rare. 



Onset characteriz- 
ed by rapid loss 
of weight. 



Possible. 



Frequent. 



Disease. 



Onset follows Onset often cha- 



symptoms of 
acute ulcer. 



racterized by at- 
tacks of colic. 



Unusual. 



Onset slow and 
marked by in- 
creasing ca- 
chexia. 



LOCAL PHYSICAL. 

Palpation. 



May be feeling of 
deep resistance 



Negative. 



Tumor near pylo- 
rus. 



Tumor tip of 9th ! L 7 er belov ^ carti " 
lk lages and may 

be nodular. 



LABORATORY. 

Chemical of Stomach Contents. 

Usually excess of 
Carbon Com- 
pound Acids. 



Excess of HC1 and 
blood. 



Same. 



'Clay" stools due 
to exeess of fat. 



Tumor of head 
of pancreas 
grossly indistin- 
guishable from 
Carcinoma. 



Feces. 



'Tar" stools. 



'Clay' stools due to! 
absence of color- Normal, 
ing matter. 



Exploratory Incision. 



m c , Dilated gall blad- 

Tumor of pylorus HAr „ B1 £iwfiii«i 
of similar type. 



der usually filled 
with stones 



Usually multiple 



CHAPTER XIII. 
GENITO-URINARY. 

Custom has more or less extensively welded these widely 
differing branches. There is less reason for their union in the 
light of to-day than there was in the past. They are further- 
more badly confused with the term 'Venereal." 

THE KIDNEYS. 

These organs are reached by one of three general incisions. 
Probably, the most common extends along the outer border of 
the erector-spinae, from a point half an inch distal to the last 
rib (to avoid wounding the diaphragm, see Fig. of this muscle 
under hernia) to a point at the level of the iliac crest. The 
incision may then turn (Konig) and sweep transversly around 
the trunk in the direction of the umbilicus as far as may be 
necessary. This incision affords the best view obtainable of 
the kidney and is indicated for the major operations as well as 
(the first part of it) for minor. 

The second incision starts at the same point and runs 
parallel to the twelfth rib one-half inch from it (diaphragm) 
for a distance of eight or ten centimeters.* This incision is a 
useful one for minor work and has the advantage of lying in 
the direction of the spinal nerves which are therefore much less 
likely to be injured than if its course lay across them. 

The kidney is also reached by a transperitoneal route. A 
ten centimeter opening is made at the outer border of the 
rectus, having its lower limit about on a line with the umbil- 
icus. When the small guts are cleared away a right angle tri- 
angle is seen, bounded above by the transverse colon, exter- 
nally by the ascending or descending colon, according to the 
side operated, and internally by a retracted mass of small guts. 
On deep retraction, the floor of this triangle will be seen to be 
white. This is the perinephritic fat. The retro-peritoneum is 

* The two systems are purposely confused. 



154 



RENAL RELATIONS. 



Level of 

- JDHZorsa.)-' / 





Fig. 37— Anterior Relations of Kidneys. 




G* 



fJ)ia.P> 


TO.§rn ^^ 




*'* *,, 






\ 


1 

1 






1 


^ 


J ** 


1 


3 


l ^ 


? 


S 


\ > 


•v 






t 


T 


\ "* 




ft 


y^ 


"K 


J" 


s y 


<: 


l *^ 


f r 


3 





T^ttfht *?'<"* *y 



/.AFT /C'c/nccj 

Fig. 38— Posterior relations of Kidneys. 



DIFFERENTIAL. 



155, 



incised in the line of the original skin cut and the kidney cap- 
sule is brought into view. This incision has certain advantages 
claimed for it, but it is objectionable because of the danger of 
soiling the peritoneum if pus be found. It, furthermore pro- 
duces greater shock than the posterior incisions. 

Nephropexy. This is a sewing of the kidney to the poster- 
ior abdominal wall. It is for the relief of floating kidney. 

This disorder is characterized by a prolapse of the organ 
distal to the umbilical plane of the body. A great many kid- 
neys are so relaxed in their attachment, due presumably to con- 
genital over-development of the fatty capsule, that they wander 
at will as far down, at times, as the pelvis. This does not 
signify anything except in the presence of symptoms and unless 
these exist to a constant and incapacitating degree, the case 
should not be operated upon. The symptoms referred to are 
often of a vague and indeterminate character, making a posi- 
tive diagnosis of the condition, except for the ability to feel the 
organ, a difficult one. It has to be differentiated from recurring 
appendicitis, nephralgia and nephrolithiasis. It may well be 
said that in order to do this, all that is necessary to do is to 
palpate the patient's side. This is true, but there are numerous 
people walking around to-day supposed to have gastritis and 
innumerable other diseases, who really have a floating kidney, 
and on the contrary, many who actually have such a lesion as 
recurrent appendicitis, are prowling around with kidney pads 
on their back. This shows the value of following some care- 
fully planned scheme for differentiation. 

DIFFERENTIAL BETWEEN 



Prolapsed Kidney 



Recurrent Ap- 
pendicitis. 



Gastritis. 



Often present. Possibly present. 
Intermittent, oft 



History of Tumor. 

Absent. 



en severe, re- 
ferred. 



Generally dyspep- 
sia or dvsuresia. 



Pain 

Intermittent, al- 
ways severe, lo- 
calized. 

Disability 



Nephrolithiasis. 



Remittent, less 
severe, localized 



Absent. 



Intermittent, very 
severe referred 
to genitals. 



Interval period 
grows shorter. 



Complete during 
Chronic dyspepsia attack. 



156 



DIFFERENTIAL BETWEEN.— Continued. 



Prolapsed Kidney 



Recurrent Ap- 
pendicitis. 



Gastritis. 



Nephrolithiasis. 



Vomiting. 



'Very frequent. 



Frequent. 



Typical in the Rare. Nausea 
morning. from pain. 



LOCAL PHYSICAL. 
Palpation. 



•Bi-manual, feel 
organ below na- 
vel. Little or no 
tenderness. 



Right sided rigid- 
ity, — may be tu- 
mor. Pressure 
pain. 



Diffuse pressure 
pain only. No 
tumor. 



No tumor. May 
be localized 
pressure pain 
along course of 
ureter. 



LABORATORY. 

Motor Power of Stomach. 



'K. I. appears in 
urine late. 


Normal. 




Very late. 


Normal. 




Cryoscopy. 




Blood freezes at 
normal tempera- 
ture. 


Normal. 




Normal. 


Apt to be raised. 




X Ray. 




Negative. Negative. 




Negative. 


Positive. 






CRYO< 


SCOPY. 





Among numerous other aids to diagnosis which have re- 
cently been developed in the study of renal disease, one of the 
most interesting is cryoscopy. In the normal individual, the 
blood freezes at a very constant temperature. 

This point varies so little, in the absence of renal involve- 
ment, that it may, for clinical' purposes be considered con- 
stant. The function of the kidney is to separate from the blood 
certain solid products of metabolism. These are removed at 
the same rate at which they are manufactured and thus the 
saline elements of the blood, which are the factors determin- 
ing its freezing point, are kept in constant relation to the 
plasma. If, however, the function of the kidney is impaired, 



SEGREGATION METHODS. 157. 

this relation changes. One of the most convenient methods of 
determining the degree of change which has taken place is to 
test the freezing point of the blood. Of course if the kidneys are 
diseased and there are more salts in the blood than there nor- 
mally should be, the freezing point will be lower, because, as 
is well known, salt water requires a lower temperature to freeze 
it than fresh. 

One would expect the converse to be true, viz. — that the 
diminished amount of solids in the urine should show in the 
same constant manner and by the same cryoscopic method as 
in the case of the blood. In the opinion of Bevan, however,, 
who with his assistant has probably done more of this work 
than anybody else, the cryoscopic testing of the urine has no 
value whatsoever. He looks upon this test as applied to the 
blood, however, as having very far reaching and important sig- 
nificance. His limits he states to be between 0.51 in a case of 
anemia and 0.78 in a case of aneuria. 

The X-Ray has been used very widely in the diagnosis of' 
nephrolithiasis. The technic has been so far perfected that it 
is now stated (Bevan, Leonard, Blake and others) to be pos- 
sible to establish a positive or a negative diagnosis of stone in 
the kidney, pelvis or ureter more certainly by this means than 
by any other. It has largely superseded Kelly's waxed tipped 
bougies, which were ureteral probes dipped in wax and then 
passed without touching anything, directly into the ureter. The 
distance to which they could be shoved up determined the 
position of the impacted stone and a microscopic finding of 
scratches on the wax proved that it had come in contact with 
the stone. 

Ureteral Catheterization has not taken such a prominent 
position as its early exploiters believed it would. This is prob- 
ably because of two reasons. First, the great difficulty in 
catheterizing the male, second and all-important the fear of 
carrying infection up from the bladder. It is a means, however, 
of obtaining urine from one kidney. 

Urinary Segregation is a method which, while probably 
more objectionable to the patient, is fraught with less danger to 
him. 

Harris' Segregator is an instrument for obtaining the urine- 



158 ARE THERE TWO KIDNEYS? 

of the two kidneys separately. It is an ingenious device by 
which a tent-like structure is inserted into and opened out in 
the rectum. The apex of the tent is directly under the trigone, 
which it lifts up. The ureteral openings then discharge into 
two little lakes, one on either side of this ridge in the floor of 
the bladder. Two fine separate tubes are carried by the in- 
strument in such manner that the ends dip into the center of 
these ponds of urine. Separate bulbs pump these ponds dry, 
the urine being poured into separate bottles. Up to date this 
is the most satisfactory means of obtaining separate urine from 
the two kidneys. Moynihan reports that a new French in- 
strument which unfolds a diaphragm in the median antero- 
posterior plane of the bladder is reliable. 

The importance of positively separating the urine cannot 
well be overestimated. In the first place, it is probably the 
most practical method of determining that more than one kid- 
ney exists. Before removing a kidney for any reason whatso- 
ever, the point must always be definitely settled that it is not 
the sole and solitary organ possessed by the patient. The ac- 
cident of removing the kidney has happened to a large number 
of able operators. Formerly there existed good excuse on the 
ground that there was no way of assuring one's self except by 
making a counter-incision. This, the chance — one in a great 
many thousand — did not seem to justify. It is most interesting 
from a pathological standpoint that, contrary to what one 
would expect, these patients who have suffered removal of their 
sole kidney and therefore are destitute of any renal excretion 
whatsoever, live usually from a week to ten days ! 

Renal Sepsis. Infection of the kidney and its pelvis may 
occur in one of two ways. A frequent source of germ invasion 
is from below, This is sometimes known under the old term 
of "surgical kidney." The infection passes upward from the 
bladder or ureter and is distributed among the tubular ter- 
minations. The other method is by deposition of germs in or 
about the glomerular tufts. They are carried here by the blood. 
This is therefore a pyemic process. 

Clinically these two methods of infection are indistinguish- 
able for their manifestations are the same. Historically they 
may differ. On section of the kidney, however, if too much de- 
generative process has not taken place, they can readily be dif- 



DECORTICATION VS. CAPSULE SECTION. 159 

ferentiated by the presence of round cell infiltration and per- 
haps of germs in the regions already referred to. Whatever 
the source of the infection, the treatment is free incision and 
drainage. 

More interest has recently centered in the results of treat- 
ing chronic parenchymatous nephritis surgically than in the 
more fully understood cases of acute renal suppuration. With- 
in the past year a large number of patients suffering from 
chronic parenchymatous degeneration of the kidneys have been 
subjected to the so-called Decortication Operation. This tech- 
nic in itself is simple enough, consisting as it does in executing 
the first part of the technic usually employed for nephropexy, 
viz. — a longitudinal central splitting of the inner capsule. 

The effects of this operation in a certain number of cases 
have unquestionably been, to say the least, remarkable. Dr. 
A. H. Ferguson showed such a case at the recent meeting of 
the American Surgical Association. The high standing of this 
operator and the unquestioned integrity of his pathological ex- 
aminations, which were made by the ablest experts and upon 
which the pre-operative diagnosis was based, renders it im- 
possible to deny that there is a place for the surgical treatment 
of chronic parenchymatous nephritis. 

It has been claimed that the good accruing to the patient 
arises from a development of a new and a large blood supply 
to the organ. This, however, seems to have been an erroneous 
supposition for Emerson, as a result of extensive experimental 
observations made at the Columbia Physiological Laboratory, 
has been able definitely to prove that, in animals at least, renal 
decortication is not succeeded by the development of an ad- 
ventitious blood supply to the kidney. It has been noticed 
that as much good may result from a simple section of the 
capsule, with or without an accompanying nephrotomy, as has 
been observed to arise from a thorough decortication. In the 
absence of proof that increased blood supply arises after this 
operation in man ; in the presence of positive demonstration 
that such blood supply does not arise in animals, and on ac- 
count of the fact that improvement is noted after a variety of 
operations in which the capsule is not torn off, it is probable 
that improvement results from an increased nerve stimulation 
rather than from an increased blood supply. 



160 SIGNIFICANCE OF BLOODY URINE. 

The ureters occasionally have to be sectioned and re-united. 
This operation is called Uretero-ureterostomy. Various de- 
vices have been employed, among others a small button and 
a diminutive hammer. The button, in a measure resembles 
Murphy's intestinal button and the hammer serves the pur- 
pose of juxtaposing the openings while suture of the serous 
coat is in progress. The union of this tube at any point is 
easy, so that throughout its length it enters more or 
less widely into operative technics. The treatment of the ter- 
minal extremity of the tube, however, is a very different con- 
sideration. It will be discussed under the bladder. 

Robert F. Weir used to say that blood in the urine meant 
in a very large proportion of cases one of three things. Stone, 
Tuberculosis or Malignancy. This affords an admirable illus- 
tration of the easy applicability and the accuracy of the Sub- 
Scheme for giving "Causes of." Hematuria is necessarily not 
the only symptom of these three important diseases, but Weir 
ingrafted that teaching on thousands of students to the lasting 
good of the public. * 

THE BLADDER. 

The importance of this reservoir centers largely upon its 
close relation to other pelvic organs. In the female it is very 
apt to be involved secondarily and by contiguous infection pro- 
cesses in malignant diseases of the uterus. It is thus often 
necessary to resect the bladder very widely. It possesses a 
remarkable power of regeneration, excellent bladders having 
been created from a dilatation of an incredibly small portion 
of mucous membrane left behind and sewed into a bag at time 
of operation. This is an illustration that nature produces or- 
gans as they are needed, but it is rare indeed that she is able 
to do so in the adult human being. 

Another important surgical consideration is the point of 
entry of the ureters. Just as in the case of the inguinal canal 
and the duodenal opening of the duct of Wirsung, so here na- 
ture has made use of the inter-muscular course. For from two 
to three centimeters the ureter passes between the coats of 
the bladder before it pierces the mucous membrane. It can 
readily be seen that malignant ; tubercular disease or injury 

* An important differential is between Nephrolithiasis, Nephro- 
tuberculosis, Nephro-malignancy and Nephralgia. 



IMPORTANCE OF URETERO-VESICAL VALVES. 161 

might make necessary the removal of so much of the ureter 
that the ends could not be juxtaposed. The problem then 
arises what to do. Even in view of the very extensive work 
which has been done in an effort to answer this question more 
satisfactorily than it was formerly answered, it is safer for the 
patient that the entire kidney should be removed rather than 
that any attempt be made to leave it in. This necessitates 
caring for the secretion by grafting the ureter either to the 
surface of the body or into the sigmoid. 

Madyl was the first to suggest the desirability of preserv- 
ing the uretero-vesical valves. He advocates cutting out a 
square of the bladder wall of sufficient size to more than in- 
clude these valves, and a transplantation of this segment di- 
rectly into the sigmoid at such a position that a convenient 
uretero-ureterostomy can be made between the proximal and 
distal ureteral ends. Some cases operated upon by this technic 
have been surprisingly successful. It is astonishing howtolerant 
the sigmoid will soon become of urine, and the quantity which 
it will hold is so great that under favorable conditions, the in- 
dividual need not void it more frequently than is habitual. 
This operation, it will be noted, converts the patient into a 
bird in that the urine and the feces are both disposed of 
through a common opening or cloaca (great sewer). 

Unfortunately even with Madyl's technic, the uretero-ves- 
ical valve is usually so impaired that infection from the sig- 
moid soon passes it, ascends to the kidney and kills the patient. 
This is why it is probably more conservative surgery in such 
cases to do a primary nephrectomy. A third important rela- 
tion to the bladder which has a definite bearing upon the sur- 
gery of the organ is that of the prostate. This gland if re- 
moved through the supra-pubic region can be reache'd only 
after anterior and posterior section of the bladder wall. The 
type of prostatic treatment instituted in a given case, there- 
fore, has an important bearing on the bladder. As will be 
explained, however, in the chapter on the prostate, this rela- 
tion is coming to have less importance everv day. 

Stones occasionally form in the bladder. A great majority 
of them grow after the manner of a snow ball, by rolling round 
and round in the bladder. There has to be a beginning or 



162 TESTICULAR DIFFERENTIALS. 

center for the concretionary mass; this may arise from 
bodies introduced from without or may come down in the 
form of small agminations of crystals from the kidney. 

Bladder stones (Brewer) may be composed of 

Uric Acid; smooth, round, dark brown. 

Ammonium Urate; lighter in color. 

Calcium Oxalate; very hard, dark brown or black, nodular 
rough surface. 

Phosphatic; white and friable. 

Composite Stones. 

Cystine j 

Xanthine { rarC ' 

Positive diagnosis of stone can be made only, either by 
touching it with a metal sound; by seeing it through the cysto- 
scope, or by the X-Ray. 

Blood in the urine, if not from the kidneys, frequently 
comes from the bladder. The most common cause of a bloody 
discharge from this organ is the so-called papillomatous tumor. 
It is a benign, pedunculated, highly vascular growth, not un- 
common in young people and always to be thought of in con- 
nection Avith hematuria. The important differential point be- 
tween this condition and the three renal causes of hematuria 
already cited is the — presence or absence of vesical irritability. 

THE TESTICLES. 

Syphilis and tuberculosis attack these organs with about 
equal frequency. The diseases, therefore occasionally have to 
be differentiated from each other as well as from the more 
common gonorrheal infection. Practically the testicle cannot 
be invaded without a certain amount of sympathetic involve- 
ment of the epididymis. This is fortunate, since without the 
epididymis as a guide, a clinical differential would be difficult 
to make. In syphilitic involvement the enlargement is almost 
always at the globus major. In tuberculous invasion the en- 
largement is in the globus minor. The syphilitic lesion there- 
fore is proximal to the tuberculous. The gonorrheal lesion 
also usually occurs in the globus minor, differential between 
this disease and tuberculosis being based upon history rather 
than physical examination. 



GROSS PATHOLOGY OF PROSTATE. 163 

For those who have been sterilized by gonorrheal infection 
of the vas deferens and epididimis it will be comforting to 
know that the occluded vas has recently been cut proximal to 
the stricture and grafted into the testicle with good functional 
result. 

THE PROSTATE. 

If, as Osier says, pneumonia is the friend of old age, 
chronic prostatitis is its bitterest enemy. A very well-known 
authority on this subject recently stated that the mortality 
from catheter life should be placed at one hundred per cent. 
Even ardent advocates of this ancient method of treating the 
chronically enlarged, obstructing prostate, are obliged to con- 
fess that the average duration of life under the catheter is not 
more than four or five years. 

Freyer (Lancet, July 23d, '04) states that the prostate is in 
reality composed of twin organs of apparently purely sexual 
function. This twin formation is seen typically among some 
of the lower vertebrates, and it is always found in man during 
the first four months of life. 

It is evident from this that instead of calling the organ the 
"prostate" we should speak of the prostates. 

There are two moot points in the gross pathology of these 
organs. First, as to the so-called "capsule." Second, as to the 
so-called middle lobe. 

Freyer likens the two organs to an orange. He states that 
the analogy would be complete if an orange segmented into 
two halves, instead of into many small pieces. Imagining such 
an orange, the true prostatic capsule is analagous to the delicate 
coat which erm lopes the edible portion of the orange. The 
"false" capsule, or what is usually known as the "capsule," 
corresponds to the thick rind of the fruit. 

The "middle lobe" does not exist as a third division of a 
single organ, as it is usually described, but is in reality simply 
the over-folded, upward-protruding margins of the two lateral 
lobes or two prostates, as they evidently should now be con- 
sidered. 

More revolutionary work has been done on the subject of 
prostatectomy in the last year than in any other department 



164 PERINEAL PROSTATECTOMY. 

of surgery. There are consequently almost no text books 
thoroughly up to date on this new surgery. The contributions 
of Young, Sims, Goodfellow and Tinker presented in 
1904, to the Surgical Section of the American Medical Asso- 
ciation offer the matter in such a new light and withal in such 
an authoritative light, that it may be looked upon as almost 
entirely remade. 

Together, they reported over one hundred and fifty cases 
of perineal prostatectomy in which there had occurred the 
astonishingly small mortality rate of less than three per cent! 
This is an utterly different teaching from that of recent text 
books, which quote mortality rates of from fifteen to twenty- 
five per cent. 

Tinker's contribution to the subject is of the utmost impor- 
tance. He has demonstrated that prostatectomy may actually 
henceforth be relegated to the domain of minor surgery! Old 
men, victims of advanced arterial sclerosis, often do not take 
kindly to a general anesthetic. Tinker injects the long puden- 
dal and the internal pudic nerve, where they course around the 
tuberosity of the ischium, as shown in the figure, with massive 
infiltration anesthesia after the method of Matas. His patients 
suffer no pain whatsoever; they complain simply of being 
wearied by their cramped position on the table. 

One of the most remarkable facts in connection with this 
subject of perineal prostatectomy is that the patients are al- 
lowed to get up and walk about their rooms in from twelve to 
thirty-six hours. They suffer no discomfort in so doing and 
prevent the possible development of hypostatic pneumonia. 

The consensus of surgical opinion, as shown at this meet- 
ing, is that the perineal operation is the technic of choice ; 
that the gland should be removed under local anesthesia, and 
that the operation should be done as early in the course of the 
disease as possible. 

Bottini's Operation. This technic has been given rather 
wide attention here recently on account of the w r ork of 
Young and others. Two years ago Young utilized it almost 
to the entire exclusion of any other technic and obtained very 
good results by so doing. He has, however, since that time 
<lone over fifty perineal prostatectomies. 

Thus the man who was perhaps better able to judge the 



LOCAL ANESTHESIA OF PERINEUM. 



165, 



advantages and limitations of the Bottini technic than any- 
other in this country has given it up in favor of the perineal 
operation. 



.Tf> 



jr 




__Qlu+ca.l Vessels 
Sop* Q)o tea. ? 7~)erre 

St,a.K* Qrtcry 

Or. Uroc.A.an.f'e-r- 



Urn*?) blia.+,c, 
T)trvc 



This figure illustrates the relation of the Inferior Pudendal and the 
Internal Pudic Nerves to the Tuberosity of the Ischium. It 
shows the ease with which they may be anesthetized in this 
situation. 

It also shows the structures emerging from the greater Sacro- 
Sciatic foramen above and below the pyriformis; viz. : 

Int. Pudic Vessels and Nerve. 



A i „ ( Gluteal Vessels. „ , 

Above \ Sup. Gluteal Nerve. Below 



Nerves to Obturator Inter- 
nus and Gemelli. 
j Sciatic Vessels, 
j Sciatic Nerve. 
(_ Inferior Gluteal Nerve. 



CHAPTER XIV. 
FRACTURES AND DISLOCATIONS. 

One of the differences between the treatment of fractures 
now and the former methods of treatment is that the fracture 
is set in a permanent dressing as soon as it is diagnosed. There 
are, of course, exceptions to this, but as a rule the "Fracture 
Box" has been discarded. 

Fractures and dislocations, which were formerly spoken of 
as compound or as simple, are now referred to as open and 
closed. 

Open fractures and dislocations are always to be kept as 
surgically clean as possible ; they have, therefore, a certain dis- 
tant relation to pathology. Especially slender has the thread 
become which unites the art of treating fractures to the science 
of medicine since the introduction of the X-ray. 

A great many new and undoubtedly more comfortable 
dressings have been introduced, but in general any dressing is 
good if it successfully concludes the treatment of the case. The 
solitary indication is that a given dressing* must reduce the de- 
formity and hold it reduced. 

Fractures cannot be reduced and held reduced except the 
anatomy of the part be properly understood. One of the most 
interesting and instructive fractures, from a purely mechan- 
ical standpoint, is that of the femur. There are three planes 
in which force is exercised to produce the characteristic de- 
formity. This fracture exemplifies so well the principle long 
taught by Stimson that the distal-fragment should always be 
put in line with the proximal. Leave the proximal fragment 
to take that position which the conflicting planes of muscle 
force will throw it into, and by as simple a contrivance as pos- 
sible put the distal fragment in line with this. Hold it 
there, and the result will uniformly be good. Attempt, how- 
ever, to force the proximal fragment into line with the distal, 
and the result will uniformly be bad. 

* Dressing here is used in a general sense. 



LINEA ASPERA. 



w 



The position taken by the proximal fragment of the femur 
depends entirely upon the length of that fragment. This is 
easily explained. The three groups chiefly concerned are the 
adductors, the flexors and the abductors or external rotators. 
When the fragment is short, as for example, if the break occurs 
from five to seven centimeters distal to the lesser tuberosity, 
all the muscular attachment of the second and third group is 
inserted upon the proximal fragment. Only a part of the ad- 
ductor insertion is upon this piece of bone, for it extends 




Fig. 40 
This shows the linea aspera pulled out sideways. 

throughout the entire linea aspera. (See cut of muscles.) In a 
fracture, then, situated at the point just mentioned, the posi- 
tion taken by the proximal fragment is that of external rota- 
tion and abduction with flexion. As the line of fracture occurs 
further and further distally, the pull of the adductors becomes 
greater and greater, for the reason already referred to ; until 
at length the adductor and the abductor pulls balance. What 
effect upon the flexion of the fragment has its lengthening? 
Obviously the longer it is the more it is enshrouded by the 
heavy vasti muscles and the leverage of the lengthening piece 
rapidly becomes so great as to obviate all evidence of flexion 
in the fragment. This occurs at about the same time that 
abduction and adduction balance each other. It is at a point 
about midway on the thigh. This explains the figure, which, it 



168 



DIFFERENTIAL OF FRACTURE. 




Dou6Pc /??cZ,7>e<C. 

/Vase 



Fig. 41 



will be noted, calls for a Nathan R. Smith splint until the 
fracture reaches about the mid point of the bone. 

Success follows a strict adherence to 
the principle that whatever the direction 
of the proximal fragment, the distal 
fragment must be made to follow it. 
The dressings suggested in the figure 
are by no means the only ones which 
will fulfill the required condition. They 
are only examples of dressings suited to 
the supposed conditions. 

The Etiology of Fracture. Direct 
Force. This is the most frequent cause 
of fracture, particularly of short bones 
and of flat bones. An exemplification 
of it is fracture by a cart-wheel having 
passed over the part. 
Indirect Force. This form of violence usually breaks the 
long bones. For example, the ribs are often broken, but they 
rarely give way at the point of application of violence. It is 
true that they may be crushed in by a very heavy blow upon 
the chest wall as of a hammer or a club, but the usual history 
of this fracture is that pressure was applied on two opposite 
sides of the body to such an extent that it was flattened until 
the ribs gave way at a point 90 degrees from the application 
of the pressure. Such forms of injury are often inflicted on 
brakemen caught between cars. Another example of this type 
of injury is seen in the bending and bursting or equatorial 
fractures of the skull which occur at 90 degrees from the point 
of application of the pressure. 

Muscular Violence. Except in the olecranon and in the 
patella, which are really nothing more than sesamoid bones, 
this cause of fracture is rare. Baseball pitchers do, however, 
occasionally break a long bone. 

The Differential of Fracture rests upon : 

(1) History of Injury, (may be very slight indeed). 

(2) Pain. 

(3) Disability: Lost or limited power. 



DIFFERENTIAL OF FRACTURE. 169* 

( a, Displacement and loss of contour. 
(4) Local Inspection < b, Angular deformity. 

( c, Swelling, ecchymosis, blebs. 

( a, Bony irregularity. 
, rt -» . t . b, False point of motion, 

(o) Palpation , ^ Referred pain. 

I d, Linear pain. (Important) 

f e\ Extension painless; compression painful.. 

| /, Rigidity. 



! C Bone. 

1 sr. Crepitus i 



, Crepitus 1 Blood. 

( Tendon. 
(This sign is the least valuable of all) 

(6) Compare with opposite side* 

(7) Mensuration. 

(8) Tendency to recur. 

(9) X-Ray. 

The details of these signs are as follows: 

Probably the most important is 

Pain. This is not peculiar to fracture at all, but, as already 
stated, is an invaluable diagnostic point in many diseases. For 
that reason, the giving of an anesthetic, while undoubtedly of 
great value, has this limitation upon it, that it takes from the 
surgeon this very important natural sign-post which points 
to something wrong. The importance of establishing a diag- 
nosis without an anesthetic is well seen in the case of early 
inflammatory lesions of joints where pain is often the only 
symptom. 

The pain of fracture has several important characteristics. 

First, the ordinary subjective pain incident to the injury. 

Second, the referred pain. This is, of course, an objective 
pain and is elicited by the surgeon pressing upon uninjured. 
regions. For example, if a fractured rib is suspected, pressure 
over the two ends of the rib will often cause the patient to cry 
out. On being asked where it hurt, he will frequently point to 
the neighborhood of the axillary line. Another good example 
of referred pain is occasionally to be seen in Pott's Fracture,. 
where pressure on the fibula, ten or twelve centimeters above 
the ankle, or pressure on the tip of the outer malleolus will 
cause the patient to cry out. He will refer the pain to the 



170 SYMPTOMS OF FRACTURE. 

usual point of fracture, viz. : four or five centimeters above 
the malleolus. This objective referred pain of bones is en- 
tirely different from the "referred pain" of nerves, which is 
entirely subjective. 

Third, and very important, is linear pain. This is consid- 
ered by many surgeons as a pathognomonic sign of fracture. 
It is well elicited by pressure along the course of the bone 
with the butt end of a pencil. The zone of tenderness will be 
found in typical cases not to be broader than a pencil butt. 
This pain is very sharp, and, when present, is of the greatest 
value. It is always present when bones near the surface are 
fractured. 

Fourth, compression pain. This form of objective pain is 
of value in differentiating fracture from dislocation. If the 
distal extremity be pulled from the proximal, in the case of 
fracture, the two sharp ends of bone which grind into each 
other and into the neighboring soft parts will be separated 
and the injury that they are causing will be stopped. Conse- 
quently the patient will at once experience relief. If, on the 
other hand, the proximal and distal portions are pressed to- 
gether, the injury done will be increased with a corresponding 
increase in the patient's pain. Dislocation is just the reverse 
of this. In it the soft parts are torn and the hard parts are 
intact. If you pull upon the distal fragment, it stretches the 
torn soft parts and it hurts the patient. Pressing the fragments 
together, however, has a negative effect. 

Ecchymosis and Blebs, when present, if they can be posi- 
tively shown not to have been caused directly by the primary 
injury, are of pathognomonic importance. If, for instance, a 
person is thrown from an automobile and lands upon his 
shoulder, it hurts more or less for a number of days, but no 
further positive evidence may be forthcoming. Perhaps after 
three or four days there will appear a little subcutaneous 
hemorrhage in the neighborhood of, usually somewhat internal 
to, the acromion. The fact that this was not there before shows 
that it is not the black and blue bruise of the primary injury, 
but that it is due to blood which has escaped from a broken 
bone and which is slowly finding its way to the surface. These 
blood extravasations follow the fascial muscular boundaries 



HOW TO LOCATE THE TROCHAUTER. 



171 



more or less and are widely influenced by gravity. Thus it hap- 
pens that the ecchymosis of a Pott's fracture is often found 
over the calcaneum just distal to the tip of the external malleo- 
lus. Probably in some cases the direction of the blood ex- 
travasation is more or less determined by the periostium. It 
would be safe in the supposed case of automobile accident 
referred to above, to say, upon the appearance of an ecchymosis 
as described, that the patient had a fractured bone. 

Blebs usually form somewhat later than ecchymosis. They 
are an equally important sign of fracture. 

Because the X-rays are not by any means always avail- 
able, as, for example, in country practice, Blake considers that 
they should be held in secondary importance for the diagnosis 
of fracture. 

Fracture of the Neck of the Femur. Nothing can be done 
with this condition until one is familiar with the landmarks. 
In a child or in a slender patient, it is easy to get one's ringers 
upon the great trochanter. In a big fat woman, however, it 
is no easy matter unless the exact position of the trochanter 
in its relation to a prominence which cannot be covered with 
fat is known. This is the anterior superior iliac spine, and the 
following method is a handy one to enable the surgeon to place 




ocha-nf'z-r. 



172 COMPARISON WITH SOUND SIDE. 

the tip of his index finger upon the tip of the great trochanter,, 
or rather to place it where it ought to be without reference to 
the fatness or the leanness of the p'atient. 

Put the patient flat upon his back. Stand by the side 
opposite to the injury. Place the fifth metacarpophalangeal 
joint of the hand which is nearer the patient's head upon the 
anterior superior spine of the injured side. Put the hand in a 
transverse plane of the body, and if the patient be an adult 
and the surgeon's hand be of usual size, the tip of the index 
finger will be found to lie directly upon the tip of the great 
trochanter. 

Very naturally it is not often necessary to resort to this 
method, but as the great trochanter is the all-important land- 
mark in determining hip injuries, and since in very fat women 
with unusually small bones, it is sometimes difficult to rind, 
the technic may occasionally be of service. 

Bryant's Triangle. This is found by dropping a vertical 
line from the ant. sup. spine when the patient lies flat on his 
back. The line passes to the table. A second line is drawn 
at right angles to it from the tip of the great trochanter. This 
it will be noticed is just about in the line of the pants pocket, 
and in an adult is about five centimeters in length. The hy- 
potenuse of Bryant's Triangle extends from the tip of the great 
trochanter to the anterior superior spine. It is of no diagnostic 
value whatsoever, and there is no practical use of completing 
the triangle, the important side of the triangle being as already 
stated, the one which lies where the seam of the pants ought 
to be. When the length of this line is determined, it should 
be compared with the length of the corresponding line on 
the well side before any significance can properly be attcahed 
to it. Comparison with the sound side is very important in 
this and in every other fracture. Individuals may vary very 
widely from the standard, but they are usually bilaterally 
symmetrical. In other words, the standard for the patient is 
not the hypothetical one in the examiner's mind, but the actual 
one, represented by the patient's uninjured side. 

Obviously, if there be a fracture of the neck of the femur,, 
this side of Bryant's triangle will either be very much reduced 
in length, or else it will actually be a negative quantity the 



COLLES' FRACTURE. 173 

tip of the trochanter having passed above the line dropped 
from the anterior superior spine. 

Nelaton's Line. This is a somewhat more difficult meas- 
ure to make because one has to find the most prominent part 
of the ischiatic tuberosity. In very fat people this is difficult 
or almost impossible to do. Nelaton noted that a line drawn 
from the anterior superior spine to the great tuberosity of the 
ischium should normally pass through the top of the great 
trochanter. If the tip of the trochanter lies proximal to this 
line, there is a fracture, unless, owing to the peculiar construc- 
tion of the individual, a similar condition exists on the unin- 
jured side. 

Colles' Fracture. This is called the "back door fracture." 
In the old days of New England, the housewives used to throw 
their dish water out the back door on the path to the out- 
houses. Walking on the same path an hour after, when the 
dish water had frozen, they frequently slipped and fell. They 
usually fell backwards, and putting their hand behind them to 
save their buttocks, they broke a wrist. Passengers attempt- 
ing to walk on board ship during a storm often fall in the same 
way. Banana peels on city pavements often cause this frac- 
ture. 

There are two interesting points to remember about Colle's 
fracture. First, almost any form of treatment seems to work 
well if thorough reduction be accomplished at the start. Un- 
less this be done, and it is surely most certainly accomplished 
under an anesthetic, no form of treatment will give a good 
result. The disability arising from improper reduction con- 
sists in the patient not being able to close the fingers. This is 
due to an inclusion of the extensor tendons in the callus. The 
second point of interest about the fracture is that it is the 
only one at which pressure at the point of fracture is permis- 
sible. A pad is usually placed in this position to aid in pre- 
venting recurrence of the deformity. 

Fracture of the Clavicle. The most successful mechanical 
contrivances are those which follow nature's mechanisms as 
closely as possible. 

Erricson, who invented the marine propeller, is said to 
have had the idea suggested to him while lying on his back 



174 MORPHOLOGY OF THE GIRDLES. 

one fall clay under a maple tree. He saw that the seeds, as 
they fell, spun slowly round and round. He conceived the 
notion that if a piece of metal were fashioned in the shape of 
the seed and its wings, it would drive a boat. 

One of the most remarkable characteristics of medieval 
architecture was the flying buttress. Shooting off from the 
sides of the main building, these delicate structures seem so 
frail as to be for decorative purposes only. Yet they are so 
proportioned that they support enormous weights. The pelvic 
and the shoulder girdles of man are interesting examples of 
flying buttresses. In the pelvis, adaptation to the upright 
position and other factors favoring ossification have caused 
that greater girdle morphologically to depart widely from the 
buttress, but the principle of transmission of the body weight 
through the pelvic bones remains the same. In the shoulder, 
a more perfect resemblance to the flying buttress has been mor- 
phologically preserved. The clavicle and the scapula are the 
integral portions of the buttress. 

Fracture of the clavicle, therefore, is of particular interest 
since its successful treatment depends upon a recognition of 
its function, which is to hold the upper extremity out from 
the body against the pull of the torso-humeral muscles and 
against gravity. After clavicular fracture these forces throw 
the distal fragment (shoulder) downward, forward and in- 
ward. The proximal fragment by muscular traction is dis- 
placed upward. Any form of treatment is satisfactory for this 
fracture if it holds the distal fragment in a position directly 
opposed to this, viz. : upward, backward and outward. 

Fractures of the Skull. Breaks in the bone-case of the 
cranium are always confusing. They may for convenience 
of description be divided, first, into those which are distin- 
guishable by their appearance. They may be depressed or 
linear. The first is caused by the application of blunt force, 
and is therefore direct. The second may be direct or indirect. 

If the fissures are multiple and radiate from a common 
center, the fracture is sometimes called stellate. 

Depressed fractures have to be differentiated from the 
circumscribed swelling which often accompanies severe local- 
ized scalp injuries. This is done by palpation. The examining 



EQUATORIAL AND POLAR FRACTURES. 175. 

finger in case of the bone injury is felt to pass over a sharp- 
edge which is not raised at all into a depression. In the case 
of the scalp injury, there is a similar depression and a similar 
ring around it, but the finger is felt to rise as it passes over 
the ring before it enters the depression. This rise is the dif- 
ferential between the two. 

Indirect Fractures of the skull are not thoroughly under- 
stood. They are the so-called Bending and Bursting fractures 
and fractures by Conte Coup. 

To understand these, even if imperfectly, it must be re- 
membered that when a blow is applied to the side of the head, 
it is, mechanically, as though an almost corresponding force 
had been applied directly at the opposite pole. This force is 
furnished in obedience to Newton's law that bodies in motion 
tend to stay in motion and bodies at rest tend to stay at rest. 
Given a skull, then, struck on one side, the opposite side of the 
skull being still, has a very decided tendency to remain still. 
The necessity of overcoming this tendency not to move puts 
pressure upon the brain-case. You then have a condition just 
exactly the same as if you had put the head between the jaws 
of a vice. 

From this point on it is not so difficult to understand how 
the bending and bursting or equatorial fractures, as they may 
be called, and the contra coup or polar fractures may occur. 

Squeeze the jaws of the vice together and fracture will 
very likely occur along the line of the equator, or in other 
words at 90 degrees from the points of application of the pres- 
sure. These are the poles. In a vice, the pressure applied on 
one side is entirely counterbalanced by the resistance of the 
opposite jaw. It does not move at all. The side of the skull 
which corresponds to the resisting side of the vice does move 
just as soon as the inertia is overcome. Perhaps it is for this 
reason that equatorial fracture does not always occur, but that 
the break is sometimes found to be at a point 180 instead of 
90 degrees from the pole where the force was applied. For 
further explanation of these fractures see Stimson's "Fractures, 
and Dislocations.*' 

It is important for legal reasons to remember that a skull- 
case may be very widely broken without exhibiting any grave 



176 TREPHINE INDICATIONS. 

early manifestations. It is not the broken bone, but the result- 
ing brain injury or infection which may cause death. 

Fracture of the Anterior Fossa is often characterized by 
sub-conjunctival hemorrhage, by bleeding from the throat 
and by paresthesia of the first nerve. 

Fracture of the Middle Fossa is characterized by a dis- 
charge through the ear of cerebro-spinal fluid. That a given 
discharge from the ear is cerebro-spinal fluid and not blood 
serum, is determined in two ways. First, its quantity. This 
is often incredible. It may, in 24 hours, saturate a pillow ; run 
through a mattress and drip to the floor. Second, by its power 
to reduce such a mixture as Fehling's solution. 

Fracture of the Posterior Fossa. The signs in this case 
are not distinctive and they appear late. There may be swell- 
ing and ecchymosis over the region, but the presence of symp- 
toms of cerebral injury, with an exclusion of anterior and 
middle fossa involvements, are more important features than 
the local ones. 

Trephining or Bone Flap Operations are two methods 
frequently employed, either to reach the brain and its mem- 
branes or to treat fractures and their complications. The 
indications for trephining are : 

(1) For disinfection of bending and bursting fractures. 

(2) Disinfection of circumscribed fracture with splinter- 
ing of inner table. 

(3) Clear cases of local pressure in simple fracture. 

(4) Removal of foreign bodies. 

(5) Arrest of bleeding (middle meningeal) and removal 
of extravasated blood. 

(6) Occasionally in simple depression. (There is a dis- 
cussion as to this point.) 

(7) Disinfection and evacuation of pus which appears 
■after injury. 

(8) Cerebral abscess. 

(9) Occasionally in traumatic neuroses. 

(10) Tumors and neuralgias of the fifth nerve. (From 
Stimson's lectures.) 

Pott's Fracture. An interesting characteristic of this 
break is that it is often mistaken both by the surgeon and by 



WHAT CONSTITUTES POTT'S FRACTURE ? 177 

the patient for a sprain. It is not uncommon to see men whose 
rough work renders them more or less indifferent to minor 
injuries, walking around with a well-developed Pott's. 

The history of such cases is as follows : By jumping from 
their truck, or in some similar exercise of their usual duties, 
they "twist their ankle." The pain may be severe, but they 
continue to work. What is the gross pathology of the part 
at this stage? There is a fracture of the fibula four or five 
centimeters above the external malleolus and there is a begin- 
ning tear at the lower extremity of the tibio-fibular ligament. 
The tibia transmits a considerable portion of the weight of the 
body to the fibula. Part of this weight reaches the fibula at 
the tibio-fibular articulation above, and part of it is trans- 
mitted by the interosseous ligament. As soon as the fibula 
is broken, all the weight that is transmitted normally to the 
bone by two agents has now to be carried by one. The natural 
result of this unusual strain on the tibio-fibular ligament is 
that it tears and that a separation of the two bones results. 

As soon as this is accomplished, whether or not the del- 
toid ligament has ruptured, or the tip of the internal malleolus 
has broken, as often happens in place of the ligamentous tear, 
the injury may be denominated a Pott's fracture. This is based 
upon an acceptance of the holding (Stimson) that the exist- 
ence of any two of the three characteristic lesions, fibula break, 
interosseous ligament tear and deltoid tear shall constitute 
a Pott's fracture. 

The patient furnishing this pathological picture usually 
finds his way into a hospital about this time. He says lie has 
a "badly sprained ankle." Upon what data is it possible to 
prove that it is not sprained, but broken ? 

Inspection. — Foot is "spayed;" in other words, a position 
of extreme plano-valgus. There may be (late) ecchymosis 
over the calcanium on the outer side of the foot. 

Palpation — False point of motion is a very important and 
characteristic sign of Pott's. It is obtained by putting the 
thumb and finger in the position of a stirrup and determining 
whether the astragalus moves back and forth in its mortice. 
Eliminate normal motion between the tarsal joints. 

By pressure on the tip of the external malleolus the frag- 



178 MODERN TREATMENT OF PATELLAR FRACTURE. 

ment may sometimes be made to rock. Referred pain may 
sometimes be obtained by pressing on tbe shaft of the fibula 
high up. Linear pain is usually very sharply marked. It is 
sometimes localized almost to a line. Find it with pencil butt. 
The treatment is dorsal flexion with plantar inversion. 
The reasons for this are obvious. The ankle is often so much 
involved that it becomes permanently stiff. While walking, at 
the termination of a tread, dorsal flexion is marked. There- 
fore, unless the patient is to certainly develop a flat foot after- 
wards, there must be marked dorsal flexion. Flat foot is the 
most dangerous sequel of Pott's. The disability suffered from 
it is often complete. It arises from constant thump during 
walking on the ball of the foot. This was never intended to 
bear such weights, and the inferior calcaneonavicular liga- 
ment soon gives way under the strain. This, of course, only if 
the ankle becomes stiff. 

Blake has shown that the treatment of patellar fracture is 
best accomplished by a careful stitching, with an absorbable 
suture, of the lateral ligaments of the patella. The important 
point is to place the stitches very close to the bone, in a line 
extending from it. This method gives much better results 
than the older one of utilizing silver wire, which inflicts dan- 
gerous traumatism on the parts at the time of operation. Such 
traumatism is an undoubted factor in favoring infection, and 
should therefore be avoided. 

DISLOCATIONS. 

Thumb dislocations are of three types. Stimson lays 
special stress upon their importance. 

Incomplete dislocations are really subluxations. They can 
be produced and reduced at will. 

Complete dislocations are those such as are commonly 
seen on the baseball field. 

Complex dislocations are generally produced by attempts 
to reduce the complete form. They are characterized by a 
button-holing of the head of the metatarsal bone between the 
tendons of the flexor brevis. It can be relieved only by open 
treatment. 

The law for the treatment of dislocations is that the de- 



ALLIS ON DISLOCATIONS. 179 

formity should be increased and the head of the bone be car- 
ried back over the same course through which it made its exit 
from the socket. The object of increasing the deformity is to 
relieve the muscular tension and relax the part. That explains 
in large measure the complicated steps of Bigelow's method. 
Allis has shown that, given a knowledge of the gross pathology, 
the reduction of any ordinary dislocation should not be at- 
tended by difficulty. Essential conditions to success are, first, 
complete anesthesia, and second, absolute immobilization of 
the proximal part. 

Dislocations of the hip _and shoulder resemble each other 
in that the head of the bone in each case almost always tears 
the capsule at its lower boundary. It is weaker here than 
above, undoubtedly because it is not necessary for it to give 
as much support to the head of the bone. 

If, as is rarely the case, the head of the humerus simply 
slips through a tear in the capsule and journeys no further,, 
this dislocation is sub-glenoid. If, however, as is usually the 
case, it does make an excursion in the tissues, it almost always 
migrates toward the coracoid process. This sub-coracoid 
dislocation is the common one. Under the impetus of extra- 
ordinary pressure the head sometimes journeys past the cora- 
coid to a position beneath the clavicle. This is known as the 
sub-clavicular form. It is rare. Occasionally the head, instead 
of coming forward, is forced backward, but this also is rare. 

The differential scheme for fractures should be applied to 
every variety of bone-break. It cannot be done here. 



CHAPTER XV. 

TUMORS, HERNIA AND MALFORMATIONS. 

A tumor is a solid swelling not the immediate result of 
inflammation. 

Cysts are swellings not the result of inflammation, but 
they are not solid. In the case of certain malignant growths 
such as epitheliomata, there can be little doubt that they are 
occasionally the indirect result of an inflammatory process. 
This frequently arises from chronic injury. 

Benign tumors owe their interest chiefly to two condi- 
tions. First, they often cause inconvenience and occasionally 
death from simple pressure. Second, they tend constantly to 
undergo malignant degeneration. 

The borderland between benignancy and malignancy is 
vague. This must continue so long as we remain ignorant of 
the causes of malignancy. All benign tumors are not so far 
removed from the malignant forms as others, and on the other 
hand some of the malignant tumors, also near to the zone 
which separates the two groups, are not far removed from the 
benign. 

Bland-Sutton's charming book deals most interestingly 
with this question, as with the entire problem of tumors, in a 
wonderfully interesting and simple manner. He approaches 
the subject by the only standpoint from which it can possibly 
be understood, viz. : that of comparative pathology. 

Granting, then, that there are certain tumors on both 
sides of the fence, about which nothing positive can be said, 
it may be justifiable, first, to give the general characteristics 
of malignancy, and, second, to attempt to differentiate between 
a benign and a malignant tumor, always remembering that 
the differential may fall flat because of the benign tumors 
having assumed malignant characteristics. 



MALIGNANT CHARACTERISTICS. 181 

CLINICAL SIGNS OF MALIGNANCY. 

(i) Rapid growth. 
(2) Pain. 
1 (3) Position. 

(4) Adherence to skin. 

(5) Ulceration. 

(6) Redness and heat. 

MICROSCOPIC SIGNS OF MALIGNANCY. 

(1) Infiltration of surrounding tissues. 

(2) Arrangement of cells. 

(3) Arrangement of blood vessels. 

(4) Character of blood vessels. 

(5) Character of cells. 

The applications of these differentials are seen in Figs. 26 
27 and 28. 

Aberration from normal developmental lines gives rise to 
the so-called terratomata and to congenital cysts. The best 
description of the origin of these cysts which are relatively 
very common is to be found in Bland-Sutton's hand book. 

Carcinomata occur on the surface of the body. There is 
an inner and an outer surface. Diverticulae of the alimentary 
canal such as the liver, the pancreas and the parotid gland lie 
upon the inner surface of the body. For this reason, and fur- 
ther because they are actively functionating glands, sarcoma 
in them is rare. They are characteristically attacked by car- 
cinomatous degeneration. (See Fig. 35.) 

Sarcomata occur within the body. 

Sarcomata of bone are frequent and are interesting. They 
are of two types, the central and the periosteal. There is a 
very great deal of difference in the treatment of these two 
types. This is because the central sarcomata are probably 
(Bland-Sutton) to be ranked with myelomata. These are 
tumors on the border line between malignancy and benignancy, 
built of tissue identical with the red marrow of young bone. 
It is thus of great importance to the patient whether the tumor 
be centrally or peripherally located, for whereas in the first 
case cure almost certainly results from a simple curettage, life 



182 



HERNIA 



in the second case can only be occasionally prolonged by dis- 
articulation of the bone. 

McCosh (Annals of Surgery, Aug., '04) states that con- 
trary to the usual belief Sarcoma is most common between the 
30th and 40th year. This is based on a careful study of ninety- 
eight cases, and is at interesting variance with the generally- 
accepted teaching that sarcomatosis is a disease of early life. 



fijisi-foi 



Spaces <if Xarray 




/s tf:sopticiqca7 Or rn '"^ 






fbssi-nc, through 



Arises 



3. 



Caz-s w 



Fig. 44 

DIAPHRAGM. 

Ensiform 

Last 6 Ribs and their Cartilages. 

Arcuate Ligaments. 

Lumbar Vertebrae. 



Internal Arcuate Ligament. — Continuous with outer side of correspond- 
ing crus and from outer side of body of 1st Lumbar, arching over the 
Psoas, to front of transverse process of 2nd Lumbar. 



INTERNAL HERNIA. 183 

External Arcuate Ligament. — Front of transverse process of 2nd (with 
slip from 1st lumbar vertebra), to apex of last rib, arching over qua- 
dratus lumborum. 

Right Cms. — From bodies and intervertebral substance of 3 or 4 upper 
lumbar vertebrae. 

Left Cms. — From bodies, etc., of upper two lumbar vertebrae. The 
tendinous portions of the crustae converge in the mid-line to form an 
arch (for Aorta, Vena Azygos Major and Thoracic Duct). The 
Fibres from the right pass in front of those from the left — they cross — 
open out— and recross after forming opening for esophagus, finally 
uniting with central tendon. 

-p.. ,. r , . ., ( Svmpathetic. 

Right Cms transmits -J ^^ ^ & ^^ Sphlanchnics . 

Left Cms transmits \ ^eft Splanchnic. 

/ \ ena Azygos Minor. 

Central Tendon. — Situated immediately below the pericardium is trifoil in 

shape. Right leaf the larger. 
Aortic 0peni7ig. — In mid-line in front of bodies of vertebrae and hence 

behind diaphragm. Transmits Aorta — Vena Azygos Major and 

Thoracic Dtict. 
Esophageal Opening. — Formed by double decussation of the Crura. 

m I* ( Esophagus. 

Transmits- „ F * , . ,r ,-.*. ■ ,- .,. 

/ Pneumo gastric Nerves, (left m front) 

Foramen Quadratum. — Placed at junction of right and middle leaflets. 

Transmits Inferior Vena Cava. 

Points of Deficiency. — Spaces of Larray: One on either side of slip to 

Ensiform. (Pus or Diaph. hernia) 

Another between attachments to 11th and 12th Ribs. 

Brewer defines hernia as a "protrusion of an organ from 
the cavity in which it is normally contained." By far the most 
frequent form of hernia occurs through the potential opening 
of the inguinal canal. The saphenous region is also a frequent 
site for external hernia. 

Internal hernia, while uncommon, occurs with sufficient 
frequency to make a differential of the utmost importance. It 
has already been touched upon while considering intestinal ob- 
struction. The usual sites for internal hernia are as follows : 

(i) Foramen of Winslow. 

(2) Aortic, esophageal and other openings and weak places 
of the diaphragm, See figure showing this muscle. 

(3) Duodeno-Jejunal . 

(4) Cecal fossae. 

(5) Sigmoid. 

(6) Preperitoneal hernia. 



184 



IMBRICATION METHODS. 



There are two important points in the technic of repairing 
external herniae. The first is the use of absorbable sutures and 
the second is imbrication. This latter is the most recent ad- 
vance which has been made in the treatment of hernia and is 
well exemplified in Mayo's technic for the treatment of ven- 
tral hernia and in Andrew's modification of the Bassini. An- 
drews accomplishes what Halsted endeavored to do, Hal- 
sted's operation, by which the cord and its appendages were 
placed on the outer surface of the external oblique, did not 
work well because the skin gave insufficient protection to the 
cord. It is obvious that a stronger abdominal wall may be 
made by uniting the three muscles rather than by having them 
split by the cord. Andrews accomplishes this tighter union, 
and, in addition, successfully protects the cord. He transplants 
it to the outer surface of the wound just as in the Halsted 
technic and then imbricates or folds fibres of the external 
oblique over it. 

In a large direct hernia, Blake sews the rectus to Pou- 
part's and closes the internal oblique over it. 



\7to*e a.na.7 ^^-r a cLcfrun^^ 




S&n. ( 7 } 



Fig. 48. 

The fanciful resemblance of the Inguinal Canal to a drum helps 
one to remember the coverings. 



INDICATIONS FOR BROPHY'S TECHNIC. 185. 

MALFORMATIONS. 

It is interesting to notice that most malformations occur 
along the central line of the body. We should, in other words^. 
suffer from very few malformations were it not that Nature 
tries to make us bilaterally symmetrical. She sometimes fails. 

Starting in the mid-line of the face, one of the most fre- 
quent malformations met with is hare lip. This is rarely in the- 
exact median line, being just to the right or left side of it. It 
may be single or double. It is rarely uncomplicated by a more 
extensive lesion, but it may exist alone. If this happily be the 
case, it is a relatively easy matter to freshen the surfaces and 
sew it up. Failure of the hard part to unite, however, usually 
accompanies it. 

Cleft Palate. The teaching on the treatment of this im- 
portant subject is destined soon to undergo very important 
modifications. This is due to the success which has attended. 
a radical operation for the deformity. Brophy has operated in 
over one thousand cases. Some of his patients are now ten 
years of age and the perfect phonetic and deglutitional results, 
can but eventually serve to bring the operation into genera! 
favor. Brophy has photographs of cases which show that, far 
from there being a deficiency of tissue, as is usually supposed 
to be the case, tissue is present in normal quantity. The cleft, 
therefore, is due, not to an absence of tissue, but to a separa- 
tion of the parts. This separation renders impossible the nor- 
mal relation of the upper to the lower gum, and this prevents 
the proper mastication of food when detentition is complete. 
Brophy therefore advises that in the first few months of life r 
and never after the sixth, the soft and easily molded bones, 
should be crushed in and held in place with lead plates con- 
nected by powerful sutures. This operation is contra-indicated 
in a child over six months of age, because ossification has so. 
far advanced that there is danger of breaking the ethmoid 
bone. This may result in cerebral infection and death. Brophy 
says that the mortality is almost zero if his technic be carefully 
followed. 

The older teaching was that the operation of uranoplasty 
should be deferred until there was evidence of impaired phona- 
tion, the lip being sewed up earlier only if the baby could not- 



186 THE MALFORMATION HIGHWAY. 

nurse. Brophy's teaching" is the reverse of this. He believes 
that the operation is not one of grave severity and urges that, 
for the sake of additional room, the lips should never be closed 
until the bone deformity has been corrected. 

Passing downward along the median line the next point 
of interest centers on the persistence of the thyroglossal duct ; 
on cysts occurring in its course, and upon the vaguely under- 
stood branchial cysts and fistulae. These are most lucidly 
described and illustrated by Bland-Sutton. Blake considers 
it possible that non-traumatic esophageal diverticulae have a 
direct relation to branchial mal-development. 

Further down, one reaches the umbilicus. Here most in- 
teresting abnormalities may occur. Through a persistence of 
the omphalo-mesenteric duct, it is possible for the contents of 
the ilium to be poured out at the umbilicus. (Patent Meckel's 
diverticulum.) If the urachus persists, there is left a free com- 
munication from the umbilicus to the bladder, and the patient's 
urine, instead of passing out through the urethra, may be 
voided at the umbilicus. 

Further down the malformation highway, one reaches the 
bladder. Extrophy is one of the most difficult to cure of all 
surgical lesions. This is because plastic work is made for- 
tuitous by the crystalization of the urinary salts upon the 
wound area. 

Hypospadias and epispadias, which, as their names imply, 
signify deficiency of the lower and upper walls of the urethra, 
represent a lesion similar to, but of less degree than extrophy. 

The uterus is a very favorite site for congenital malforma- 
tions. Women occasionally retrograde to the marsupials. 
These anomalous vertebrates possess, among other very in- 
teresting organs, a bicornate or double uterus. Instead of the 
fallopian tubes ending as they normally do, they continue 
downward through the body of the uterus, thus forming two 
cavities. 

The Rectum is not infrequently the scene of faulty or ir- 
regular development. The anus may be imperforate, due, sim- 
ply to the drawing across it of a single fold of modified skin. 
This deformity is, of course, easily corrected by puncture. The 
normal rectal opening is brought about by a dimple on the 



RECTAL DIFFERENTIALS. 187 

surface which gradually deepens as development proceeds until 
it reaches the end of the hind-gut. It is easy to understand 
that a very slight hit or miss on the part of Nature would 
either not carry the hind gut far enough down below the sacral 
promentary to allow of its coming in contact with the dimple, 
or the dimple might either not be placed in just the right posi- 
tion or be of the requisite depth. Further, the fusion of the 
dimple's bottom and the termination of the hind gut may not 
take place. Imperforate anus, therefore, is not uncommon. 
Fear of it is what makes it necessary in all the maternity hos- 
pitals for the medical students to record the baby's daily rectal 
temperature. Doing it once would suffice. 

A recollection of the fusion of this dimple with the gut 
serves to keep in mind a differential point of great clinical im- 
portance. Carcinoma is known to be most apt to occur where 
there is a line of junction between skin and mucous membrane. 
This line of junction in the adult is from three to five centi- 
meters within the rectum. That is why, if you can feel with 
the finger a stricture in the rectum, it is apt to be malignant. If 
you cannot so feel it, it is apt to be syphilitic. It is easier to 
remember this point because of its developmental relations 
than by brute memory. 

Over the sacrum or indeed anywhere along the course of 
the spinal canal, but much more frequently low down than high 
up, one sometimes sees the lesion called spina bifida. This 
congenital defect is due to a failure of the laminae to develop 
sufficiently to enclose the cord. With or without its mem- 
branes, it escapes into the soft tissues. Radical treatment is 
to-day usually successful. 

Wens occasionally occur along the sagittal line of the head. 
It is dangerous to operate upon them in this position, how- 
ever, for fear that, instead being wens, the tumors may 
in reality be meningeal encephaloceles, the cerebral counterpart 
of the spina bifida of the cord. 



CHAPTER XVI. * 
ANIMAL PARASITES. 

Comparatively few animal parasites cause diseases in man 
which necessitate surgical intervention. Due to improved 
methods of diagnosis, however, there have recently been re- 
ported an increased number of instances where certain animal 
organisms have so invaded various parts of the body as to 
compel active surgical treatment. 

The platyhelminthes are the chief offenders, and of these 
the most important are trematodes, cestodes and certain of the 
nematodes. 

Of the cestodes, the Tenia Solium (the common pork tape) 
and the Tenia Echinococcus (tape of the dog) are the most 
frequent causes of lesions which necessitate surgical inter- 
vention. 

Or the nematodes, the Ascaris lumbricoides (the round 
worm) ; certain of the filariae, such as the F. sanguinis hominis 
and F. humani oculi; and one of the anguillulidae, the anguil- 
lula-aciti, or vinegar eel, merit mention. 

The Hematobium Bilharzia is the single trematode of any 
human surgical importance. 

As to the surgical significance of Protozoa, little is to be 
said. Some cases of amebic dysentery may ultimately require 
surgical treatment. (See colostomy.) Amebic liver abscess 
has also been referred to. 

The Tenia Solium, unlike the T. mediocanalata, is capable 
of causing serious surgical lesions in man. This parasite gains 
entrance to the body through the patient's eating uncooked 
pork, infected with the cysticercus. This produces in the ani- 
mal a so-called "measly" condition (cysticercus cellulosae). 
The cysticercus develops in the brain, eye, heart and other or- 

* The subject matter of this chapter has been kindly furnished by 
Dr. William R. Stone. It is abstracted from his ms. of a text-book on 
Animal Parasites, which is in preparation for the press. 



CYSTICERCI. 189 

igans. It is only rarely seen in the liver and never in the bones. 
In the brain, the cysticerci are usually found in the membranes 
of the cortex more rarely in the brain substance. Yon Graefe 
estimates that in the Berlin opthalmic practise the cysticercus 
is observed in the eye once in every thousand cases. In this 
organ it is most commonly located beneath the retina ; about 
half as frequently it appears in the vitreous humor, and, rarer 
still, is met with in the anterior and posterior chambers. When 
in the aqueous or vitreous humors the movements of the para- 
site's head may readily be seen. 

Cysticerci developed in the arachnoid or pia often have a 
peculiar branched appearance. This has given rise to the mis- 
leading name of cysticercus racemosus. Here the parasite may 
grow to great size (8-25 cm.) and have many branches and 
diverticulae. This peculiar shape is probably due to the pres- 
sure conditions under which it grows. In the brain ventricles 
the parasite may attain the size of a pigeon's egg. 

Sometimes the cysticerci develop in the skin, beneath the 
cutis, where they produce small tumors the size of a pea. When 
present in the skin or eye, the diagnosis of obscure coincidental 
brain disease is made easy. 

Unless early removed, cysticerci in the eye lead ultimately 
to the destruction of the organ, and, in some instances, to 
sympathetic involvement of the other eye. 

In the brain the symptoms are those of any similarly 
placed brain tumor and the only treatment is surgical. 

Tenia Echinococcus. — Yon Siebold first described this tape 
worm. It is of comparatively small size and possesses only 
three or four segments. At maturity the terminal segment 
exceeds the rest of the worm in size. The parasite has about 
forty hooklets springing from a somewhat swollen rostellum. 
These worms are found, often in immense numbers, in the up- 
per portion of the small gut of the dog. When the ripe ter- 
minal segment breaks off, it is carried out in the feces. Either 
during transit through the dog or after reaching the outer 
world it bursts and liberates the contained ova. They are en- 
closed in a tough chitinous envelope. After finding their way 
into the stomach of man, this covering is dissolved by the 
combined action of the body heat and the gastric juices. The 



190 HYDATID DISEASE. 

embryo, being set free, trecks through the tissues of the gut 
into other organs. Here they begin asexual development. 

In the earliest stages at which they have been observed, 
the ova consist of solid spherical bodies measuring 0.25 to 0.35 
mm. in diameter and have a striking resemblance to a mam- 
malian egg. Their development (ontogenetic) follows the early 
stages of mammalian development (phylogenetic), but is not 
completed as in the higher forms. This developmental relation- 
ship is thought by many to show that vermes are not so far 
removed from ourselves as the differences in the adult forms 
would lead one to think. 

The "brood capsules" and scolices arise from the germinal 
layer as minute elevations by proliferation of the cells of the 
layer. The head, or scolex, first appears as a discoidal thicken- 
ing in the wall of the brood capsule ; on the tip of this discoidal 
thickening, the hooklets and suckers of the head are formed. 

Some hydatids contain no scolices, and the absence of 
scolices is frequently associated with the absence of daughter- 
bladders. This condition is known as a sterile hydatid. 

Hydatid disease occurs in many countries. Iceland and 
Australia are its chief homes. In Iceland it is estimated that 
1-16 to 1-58 of the entire population is affected by this disease. 
Leuckart says that in central and northern Germany the dis- 
ease is not infrequent. In China it is extremely rare. Osier, in 
1882, was able to record only sixty-one cases for the whole of 
the United States and Canada. In England, however, it is not 
so uncommon. 

Symptoms of Hydatid disease. These vary in different 
portions of the body, but when the hydatid cyst is situated in 
an organ, interference with the functions of that organ varies 
inversely with the ability of the organ to expand at the same 
rate as the slow-growing cyst. 

After a hydatid cyst has been punctured for purposes of 
diagnosis or treatment, an urticarial rash often makes its ap- 
pearance within a short time. This is usually general, and lasts 
from a few hours to one or two days. It has been noticed 
after the spontaneous rupture of the cyst into one of the large 
serous cavities. With infection of the cyst, the symptoms are 
those of abscess and concomitant pyemia. 



SURGICAL TREATMENT OF HYDATIDS. 191 

Diagnosis is often easy ; at times it is difficult, or even im- 
possible. The tumor is usually rounded, firm, smooth and" 
elastic without antecedent or present symptoms other than 
those due to its size. It is yielding and imparts a thrill on 
percussion. A hypodermic syringe should be used to draw off 
a small quantity of fluid, and if this fluid is found to contain 
scolices, hooklets or a piece of the cyst wall, the diagnosis is 
final. If these are not present, the character of the fluid must 
be depended upon to differentiate it. It resembles two other 
fluids found in the body ; the cerebro-spinal and that of some 
forms of hydronephrosis. An absence of symptoms referable 
to these regions will differentiate the diseases. 

Treatment. — This is always surgical and should have for 
its final aim either (A) Palliative measures which look to the 
death of the parasite, e. g. (i) Internal administration of drugs, 
(2) Acupuncture. (3) Electrolysis. (4) Injection of fluids 
into the cyst after the removal of some of its contents. (5) 
Aspiratory puncture and withdrawal of the fluid. 

Or (B) Radical measures which aim at the complete re- 
moval of the parasite : (1) Recamier's method : opening is made 
with caustics. (2) Long-continued drainage and evacaution 
through a permanent canula. (3) Simon's method: double 
puncture with small trochars, followed by incision. (4) Various 
forms of direct incision with immediate or delayed removal of 
the parasite. 

Distribution of hydatid in the body. — Thomas, in 1,90a 
cases from various countries, finds that the frequency with 
which the different organs are attacked is expressed in the 
following percentages: Liver, 57 per cent; lungs, 11. 6-10 per 
cent: kidney, 4.7-10 per cent; brain, 4.4-10 per cent; spleen, 
2.1-10 per cent; heart, 1.8-10 per cent; peritoneum, omentum 
and mesentery, 1.4- 10 per cent. 

THE TREMATODES. 

Ascaris Lumbricoides. Some time ago Dr. Robert T. 
Morris made a diagnosis of the presence of one of these para- 
sites in the vermiform appendix. Operation confirmed the diag- 
nosis. 

In the pathological laboratorv of the Lmiversitv of Penn-- 



-192 FILARIAK. 

sylvania there is a specimen of a liver and gall bladder which 
shows the bile passage to be completely blocked by this organ- 
ism. In this case, the symptoms previous to death were those 
of gall stones. These worms have also been known to enter the 
eustachian tubes or nasal ducts, and through these to have 
found their way to the external world. Kidney, spleen, pleura 
and urinary passages have sheltered stray specimens of these 
parasites at times ; they have even been known to escape by 
the urethra. 

Filaria oculi humani. Under this name are included sev- 
eral minute flariae, which, from time to time, have been found 
either in the crystalline lens, in the vitreous, or aqueous hu- 
mors. These filariae are identical with those found in some- 
lower vertebrates. 

Filaria Sanguinis hominis. The organism is the cause of 
chyluria and lymph-scrotum ; varicose groin glands, chylocele; 
certain varieties of lymphorrhagia, endemic lymphangitis, 
orchitis, and varieties of cellulitis. Endemic elephantiasis 
arabrim is probably dependent upon the same cause. 

The Filariae Sanguinis hominis are long, slender, trans- 
parent, gracefully formed, snake-like organisms, which, when 
seen under the microscope in newly drawn blood, exhibit a 
remarkable activity. They coil and uncoil ; wriggle and lash 
about with incessant movements among the blood corpuscles. 
The parasite in parental form inhabits the tissues, lymphatics, 
or blood vessels, while the parasite in adolescent form circulates 
in the blood-stream. There are three chief varieties of this 
parasite, but Patrick Manson has described five. Those most 
commonly met with are : F. diurna, which appears in the cir- 
culating blood during the day, disappearing during the night ; 
P. nocturna, appearing during the night and disappearing dur- 
ing the day ; F. perstans, which is present both day and night. 

The filariae are to be found most often in tropical coun- 
tries, such as Brazil, Mauritus, India, China and the West In- 
dies ; certain isolated cases have been recorded in individuals 
living in temperate climates and who have never visited tropic- 
al countries. Both. sexes are liable to the disease. In women, 
its first appearance may date from a pregnancy; in men, very 
often from some unusual physical effort. 



SYMPTOMS OF CHYLURIA. 193 

Symptoms. — The characteristic symptoms of chyluria ap- 
pear suddenly. There may be retention of urine, which may 
pass off spontaneously. The urine is milk-white, pinkish or 
red, like blood. This condition may last for a few days, for 
weeks, months, or even years. The urine may then become 
normal, only to return at intervals to the same condition. In 
certain cases the glands of the groin are found to be prominent 
and the ducts varicose. The lymphatics of the scrotum may 
be similarly dilated. 

The filariae may be found in the urinary sediment. 

The presence of clots at once distinguishes chyluria from 
such purulent conditions of the urine as are associated with 
pyelitis, abscess rupturing into the urinary tract, and cystitis ; 
from phosphaturia, etc. In the case of chyluria complicated 
by endemic hematuria, the presence of Bilharzia ova along with 
the filariae will clear up the diagnosis. 

Lymph-scrotum is almost a certain indication of the pres- 
ence, actual or past, of F. nocturna in the lymphatics. On in- 
specting such a scrotum, it is found to be more or less enlarged, 
thickened, and covered in places by lines or groups of non-in- 
flammatory vesicles. The contents of these vesicles may in- 
clude living filariae. 

Orchitis is a common complication. The condition known 
as chylocele may be met with. Here the tunica vaginalis may 
contain a milky fluid, exactly similar in character to that found 
in lymph scrotum. Chylous fluids are also found in certain 
cases, in the peritoneum and pleurae, as well as in other por- 
tions of the body. 

Elephantiasis Arabum implies an elephantoid condition 
of the integument, in any portion of the body. (See chapter 
on Lymphatics.) 

Treatment. — In the vast majority of instances this is medi- 
cal. In certain cases, however, of lymph-scrotum and orchitis, 
the parasite having been found to be single, has been removed 
by incision. 

ANGUILLULA ACITI. 

This is the common vinegar eel. C. Wardwell Stiles, 
of the Bureau of Animal Industry, has reported the only case 



194 BILHARZIA CYSTITIS. 

in which this parasite has made man its host. This case oc- 
curred in a -woman, and the organism was removed from the 
patient's bladder, where it had produced an acute cystitis. It 
was supposed that the parasite had gained entrance into the 
bladder by means of a douche containing vinegar. This is 
thought by some laymen to be a means of preventing concep- 
tion. 

Bilharzia hematobia. This parasite belongs to the dis- 
tomata, and its chief interest surgically lies in its causation of 
cystitis. Its natural habitat is ethiopic. It is extremely abun- 
dant in Egypt, Axim, Acra and other places on the west coast 
of Africa. Within the past year a case has been discovered in 
the French Hospital of Xew York City, and was reported by 
Chas. H. Peck. The parasite is about 7 to 16 mm. long, and is 
covered with fine tubercles. It resembles threads of the finest 
white silk, and is usually unbranched. The ova and contained 
embryos are bright, translucent, flattened not unlike a melon 
seed. One end is blunt, but the other is provided with a sharp 
spine. The average length is 1-200 to 1-160 of an inch, and the 
breadth about one-half of this. The shell is hard and trans- 
parent. The embryo lying within this is covered with ciliae, 
which, when mature, may be seen to move. 

The Symptoms are often sudden in onset and come on 
after a period of incubation of about four months. 

Generally the urinary bladder is the first organ to show 
involvement, though sometimes a false dysentery may be the 
initial sign. If the posterior portion of the bladder alone be 
involved, there is but little pain. Most frequently, however, 
the neck of the bladder and the urethra is involved, in which 
case there is pain on micturition, tenesmus, irritation and 
supra-pubic pain. There mav be priapism, perineal pain and 
seminal emissions if the prostate and seminal vessices are in- 
volved. General cystitis is rare. 

The Urine. Haematuria does not usually come on at first. 
The gross examination may show nothing but small, brilliant, 
scarlet, pin point specks. Under the microscope there mav be 
a few pus cells, blood corpuscles and ova. Later, the urine 
becomes smoky and sometimes bloody ; especially in morning 
specimens. This is due to the presence of the organism, ova, 



BILHARZIA HEMATOBIA. 195 

blood clots, corpuscles, pus and crystals of various salts. In 
course of time, as the disease progresses, the numbers of or- 
ganisms and ova in the urine increase until they may be present 
in thousands. 

Treatment. — This is medical, aiming at the support of the. 
patient's strength. If, as is often the case, a calculus forms, it 
must be dealt with surgically. 



LIST OF HOSPITAL EXAMINATIONS 

For 1902. 



BELLEVUE HOSPITAL (P. & S. Division) 

BROOKLYN CITY HOSPITAL 

FRENCH HOSPITAL 

GERMAN HOSPITAL 

HUDSON STREET HOSPITAL 

J. HOOD WRIGHT HOSPITAL 

MT. SINAI HOSPITAL 

NEWYORK HOSPITAL 

SENEY HOSPITAL, Brooklyn 

ST. LUKE'S HOSPITAL 

ST. JOHN'S HOSPITAL 



EXAMINATION PAPERS FOR 1902. 



BELLEVUE HOSPITAL (P. & S. Division.) 
April 5th, 1902 

QUESTIONS IN ANATOMY. 

1 — Draw a cross-section of the middle of the right arm, show- 
ing the relation of the various anatomical structures. 

2 — Name the veins of the neck which receive the blood from 
the head and face; give their origin and anastomoses. 

3 — Describe the origin, course and muscular distribution of the 
anterior crural nerve. 

4 — Name the viscera or portions of same contained in the fol- 
lowing regions: Right hypochondriac, epigastric, hypogas- 
tric and left iliac. 

SURGERY. 

1 — What swellings may occur around the wrist joint ? 
2 — Give symptoms of: 

(a) Sacculated Aneurism. 

(b) Extra Dural Hemorrhage. 

3 — Give causes and treatment of retention of urine. 

PRACTICE. 

1 — Write all you know about Malig. Endocarditis. 
2 — Treatment of Pericarditis beginning as dry pericarditis and 
passing on to large pericardial effusion. 

MATERIA MEDICA. 

1 — Describe symptoms and treatment of carbolic acid toxemia 
taken with suicidal intention. 

2 — Write prescription and directions in full for treatment of 
tape -worm. 

3 — Enumerate the official prescriptions of Hyoscyamus, aco- 
nite and digitalis and alcaloids of each, and give strength 
and dose of each preparation. 



200 

BROOKLYN CITY HOSPITAL. 

1 — Causes of albuminuria and some of the conditions and dis- 
eases in which it may occur. Treatment of acute 
dysentery. 

2 — Describe microscopically and macroscopically the large 
white kidney. 

3 — What are the important clinical differences in course, prog- 
nosis between compound fracture of a limb, by direct and 
indirect violence. 

4 — Briefly give treatment of Hallux Valgus 

5 — Give treatment of Pelvic Peritonitis. 

G — Describe the Internal Oblique Muscle. Describe Ureters, 

7 — Give evidences of pregnancy as they exist at the end of the 
third month. 

Describe the conduct of the first stage of labor. 



GERMAN HOSPITAL. 

Brooklyn. 

ANATOMY. 

1 — 'Describe tonsils and give blood supply. 

2 — What muscles move the fingers and what nerves supply 
these muscles. 

PHYSIOLOGY. 

1 — What is the chemical action of the bile in the alimentary 

tract. 
2 — Describe the mechanism of the heart's action, particularly 

how the refilling of the auricle in diastole takes place. 

MATERIA MEDICA. 

1 — Give the physical and chemical properties of atropine, deri- 
vation and therapeutic properties. 

2 — Give the remedial action on colds, the various methods of 
its application and indications therefor. 

GENERAL MEDICINE. 

1 — Give the causes and treatment of hemoptysis. 
2 — Give the diagnosis of variola. 



201 
GENERAL SURGERY. 

1 — Give the differential diagnosis between benign and malig- 
nant stricture of the oesophagus. 

2 — Give the clinical signs and symptoms demanding trephin- 
ing following head injury. 

OBSTETRICS. 

1 — State the preventative treatment of eclampsia. 
2 — State the possible termination in the mechanism of a face 
presentation. 

GYNECOLOGY. 

1 — State the differential diagnosis of a small ovarian tumor and 

extra uterine pregnancy at the tenth week. 
2 — State the etiology and symptoms of endometritis. 



HUDSON STREET HOSPITAL. 

MEDICINE. 

1 — Give the differential diagnosis between cerebral hemor- 
rhage and uremia. 
2 — Give the characteristics of sputum in : 

(/) Lobar Pneumonia. 

(2) Acute Bronchitis. 

(j) Bronchial Asthma. 

(./) Pulmonary Gangrene. 

(j) Pulmonary Actinomycosis. 
3 — Give the physical signs of Mitral Stenosis. 
4 — Describe the lesions found in fatal cases of malaria. 
5 — Mention the causes and give the symptoms of embolism of 
the pulmonary artery or its branches. 

MATERIA MEDICA AND THERAPEUTICS. 

1 — Giye symptoms of acute poisoning by Nux Vomica. 

2 — Write, without abbreviations, a prescription for an adult 

with acute bronchitis, 
3 — Give the full official name and dosage for administration in 



"202 

solution by mouth, of a preparation of an alkaloid of each 
of the following drugs: 

Nux Vomica. 

Cinchona. 

Coffee. 

Opium. 

Belladonna. 

4 — Give antidotes, stating whether physiological or chemical, 
of the following poisons : 
Opium. 

Sulphuric Acid. 
Carbolic Acid. 
Nux Vomica. 
Bichloride of Mercury, 

SURGERY. 

1 — Define concussion of the brain. 

^2 — Give the symptoms of compression of the brain following 
injury of the middle meningeal and hemorrhage between 
the dura and the skull. 

-3 — State the conditions possibly underlying cellular emphy- 
sema after injuries of the thorax. 

4 — Give the diagnostic features of strangulated scrotal hernia. 

-5 — Give the treatment of popliteal aneurysm. 

ANATOMY. 

1 — Indicate by diagram the guides to and positions of the fis- 
sures of Rolando and of Sylvius. 

2 — Give the relations of the cervical portion of the esophagus. 

3 — Describe the acromioclavicular -joint. 

4 — Describe the collateral circulation developed after ligation 
of the superficial femoral at the apex of Scarpa's triangle. 

-5 — Name the^ structures in relation with the ankle joint, indi- 
cating their relations with each other. 



FRENCH HOSPITAL. 

1 — Give diagnosis of acute pneumonia. 

2 — Give the diagnosis of Hemoptysis and its treatment. 

•3 — Give a prescription for acute articular rheumatism. 



203 

4 — What is the diagnostic significance of leucocytosis? 

5 — What is the significance and value of Widals reaction? 

6 — Describe the management of a case of chronic dysentery. 

7 — Describe the axillary space, giving boundries, contents and 
relations. 

8 — Give the relations of the right kidney. 

9 — (a) Give the differential diagnosis of irreducible inguinal 
and femoral hernia, 
(b) Describe Bassini's operation for inguinal hernia. 

10 — Describe fibro-myoma of the uterus; indications for surgi- 
cal treatment and the various methods for meeting them. 



J. HOOD WRIGHT HOSPITAL. 
ORAL. 
1 — Tell what you see in specimen of urine. 

1 — How would you treat hemorrhage from mouth. 
2 — What is the significance of a headache? 

1 — What is the nerve supply of skin on back of hand? 

2 — What is the action and nerve supply of tibialis anticus? 

3 — What muscle is crossed by the Phrenic? 

4 — What are the complications of fracture of the arch of the 

pelvis? 
5 — What are the objective signs of subcoracoid dislocation of 

humerus ! 
6 — How would you treat retention of urine? 

ANATOMY. 

1 — Describe the deep epigastric artery and give principal sur- 
gical relations. 

2 — Name different ways by which lesser peritoneal cavity may 
be entered and name structures and organs covered by 
lesser peritoneal sac. 

PATHOLOGY, 

1> — What causes influence the number of polymorpho-neu- 
clear, neutrophilic leucocytes. 



204 

SURGERY, 

1 — Give symptoms of perforation of ulcer of stomach, princi- 
pal conditions from which it may be differentiated and out- 
line of surgical treatment. 

MATERIA MEDICA, 
1 — Digitalis, dose and physiological action. 

PRACTICE. 
1 — Edema of lungs, causes, symptoms and treatment. 



MT. SINAI HOSPITAL. 
Questions by Dr. Howard Lilienthal. 

ANATOMY. 

1 — The gall-bladder and its associated ducts. 
2 — Describe the prostate. 

3 — What is the usual deformity in complete fracture or the 
lower fourth of the femur and why does it occur? 

\ SURGERY. 

1 — Describe briefly the method of inducing anesthesia by the 
inhalation of Nitrous Oxide Gas. Ether. Chloroform. 

2 — Describe the steps in an aseptic amputation of the thigh 
through its middle third, giving reasons for the methods 
which you would employ. 

3 — A man of fifty years of age, well nourished and with a neg- 
ative past history is admitted to the hospital after suffering 
for forty-eight hours with acute general cramp-like abdo- 
minal pain which for the past few hours has become local- 
ized in the right lower iliac region. The man vomited 
several times during the first day and the bowels have not 
moved since the attack began. Urination is frequent and 
rather painful, but little high-colored non-albuminous 
urine being voided at a time. The tongue is dry and 
slightly brownish. The pulse rate is 110 and somewhat 
irregular. The temperature is 100° F. There is consider- 
able abdominal rigidity and tenderness, on palpation the 
expressions of pain being more marked on the palpation 



205 

of the right iliac region. No mass can be felt. On per- 
cussion the greater part of the abdomen gives a tympanitic 
or intestinal resonance but there is an area of marked dull- 
ness or even flatness in the hypogastrium. 

Discuss this case. Give diagnosis and treatment. 
What would you consider your duty as House Surgeon? 



Questions by Dr. B. Sachs. 

1 — Give the symptoms of: 

a, Tabes Dorsalis. 

£, Disseminated Sclerosis. 

c, Multiple Neuritis. 

d, A tumor occupying the middle portion of the left 

anterior central convolution. 

2 — State the various forms of iritis and the treatment of each. 

3 — Give the exact drug treatment in cases of incipient tuber- 
culosis of the lungs, of extreme anemia, of constitutional 
syphilis, of the early stage of typhoid fever. 

Write a prescription calling for suppositories to be given for 
the relief of severe pelvic pain. 



Questions by Dr. J. Rudisch. 

1 — Character of urine in contracted kidney, waxy kidney, and 

acute Nephritis. 
'2 — Changes in the blood and urine in typhoid fever. 
3 — Differential diagnosis between typhus and typhoid. 
4 — Characteristics of influenza pueumonia. 
5 — In what acute diseases are joint inflammation particularly 

apt to occur. 
6 — Treatment of hemorrhage of the bowels in typhoid. 
7 — Ultimate results of gastric ulcer. 

8 — Causes of hypertrophy of the left ventricle of the heart. 
9 — Diagnostic features of variola. 



206 

NEW YORK HOSPITAL. 
ANATOMY. 

1 — Describe the lymphatic system of the breast and the : 

(a) Arrangement of axillary lymph nodes, 

(b) Arrangement of sternal lymph nodes, 

(c) Arrangement of anterior mediastinal lymph nodes. 
2 — Give the relations of the Prostate Gland. What is its func- 
tion? 

3 — With what bones does the Os Magnum articulate ! 

THERAPEUTICS. 

1 — Discuss the therapeutic uses of and the indication for vene- 
section. 

2 — Discuss Salicylic Acid and its derivatives. 

(a) Indications for its use, 

(b) Advantages and disadvantages of three prepara- 

tions with dosage of each. 
3 — Name three drugs that may be used as intestinal antiseptics, 
with dosage of each when so used. 

PRACTICE OF MEDICINE. 
1 — Cholelithiasis. 

(a) State the usual composition of gall stones. 

(b) State the general and local conditions which favor 
the formation of gall stones. 

(c) State the lesions produced in the gall bladder, 

liver and adjacent parts. 

(d) Describe the symptoms of biliary colic. 

(e) Give the differential diagnosis between biliary 

colic and other morbid conditions that may simu- 
late it. 
(/) Give the preventative remedial and surgical treat- 
ment. 
2 — Hodgkin's Disease (synonyms, Lymphadenoma, Pseudo- 
leukemia, etc.) Discuss the etiology, symptomatology 
and treatment. 

SURGERY. 

1 — Retropharyngeal abscess. 

Etiology, symptomatology, operative treatment. 
2 — Exophthalmic Goitre ('Graves' or Basedows's Disease'). 

Etiology, symptomatology. 



207/ 

METHODIST EPISCOPAL HOSPITAL. (SENEY) 

Brooklyn, March 26th, 1898. 

WRITTEN EXAMINATION FOR INTERNES. 
ANATOMY. 
1 — Describe the esophagus and give its surgical relations. 

2 — In what respects do the hip and shoulder joints resemble- 
each other and in what do they differ ? 

GENERAL SURGERY. 

1 — Mention six of the more important complications that may 

attend or follow fracture of an extremity, 
2 — State the varieties, predisposing and exciting causes, and 

treatment of inguinal hernia. 

GENITO-URINARY SURGERY, 

1 — Describe the etiology and pathology of chronic ovaritis. 
2 — Give the causes and symptoms of kidney abscess. 

PHYSIOLOGY. 

1 — How much carbon dioxide is normally excreted by the 
lungs under ordinary conditions of exercise, etc. ? 

2 — Name the more important constituents of the gastric juice* 
and briefly describe gastric digestion. 

MATERIA MEDICA. 

1 — State the therapeutic uses of colchicum. 

2 — What is the derivation and therapy of gutacol? 

OBSTETRICS. 
1 — State the treatment of transverse presentation. 
2 — State causes and treatment of retained placenta. 

PATHOLOGY. 

1 — What are the pathological differences between Hodgkin's 
disease and leucocythemia? 

GENERAL MEDICINE. 

1 — State the symptoms differential diagnosis and treatment of- 
cancer of the stomach. 



•208 

2 — What are the symptoms and what is the treatment of infan- 
tile scurvy? 

March 29th, 1902. 
ANATOMY. 

1 — How would you apply a trephine to expose: 

{a) the mastoid antrum, 

(b) the lateral sinus ? 
"2 — Give the sensory nerve supply of the upper extremity. 

GENERAL SURGERY. 

1 — Give the differential diagnosis between the different forms 

of intestinal obstruction. 
~2 — Give the indications and contraindications for amputation 

in gangrene. 
o — State the complications and sequelae of penetrating gunshot 

injuries of the chest. 

GENITOURINARY SURGERY. 

1 — Enumerate the causes of hematuria. 

-2 — Give the symptoms of transperitoneal rupture of the urinary 

bladder. 
3 — Describe the symptoms and complications of floating kidney. 

GENERAL MEDICINE. 

1 — Describe the symptoms and course of acute anterior polio- 
myelitis. 
2 — State the varieties, symptoms, and differential diagnosis of 

arthritis deformans. 

OBSTETRICS. 

I — Give the diagnosis and management of placenta previa. 
2 — State the differential diagnosis of ectopic gestation. 

THERAPEUTICS. 

1 — Give the therapeutic action of: 
(a) amyl nitrite, 
(/?) thyroid extract. 

PHYSIOLOGY. 

1 — How do proteids differ from peptones? 

2 — Describe the more important functions of the spinal cord. 



209 
PATHOLOGY. 

■Give the differential diagnosis, as based on an examination 
of the blood, between typhoid fever and malignant endo- 
carditis, and describe the post-mortem findings in both 
diseases. 



ST. LUKE'S HOSPITAL. 

INSTRUCTIONS FOR CANDIDATES. 
April 7th and 8th, 1902. 

1 — Each candidate is furnished with questions" on Materia 
Medica, Practice, Anatomy and Surgery, for written ex- 
amination. 

2 — Assemble at Hospital again on Tuesday, April 8th, at 2.15 
P. M , for practical examination, etc. 

ANATOMY. 
1— Triangle of Petit. 
2 — Nerve supply of trapezius. 
3 — Give articulations of tarsal bones. 

4 — Through what foramina of the skull do the following struct- 
ures enter or leave the skull : 

(/) Middle meningeal artery. 
(2) Internal carotid artery. 
(j) Facial nerve. 

(4) 9th nerve. 

(5) 10th nerve. 

(6) 12th nerve. 

MATERIA MEDICA. 

1 — Treatment of opium poisoning. 
2 — Medical uses of quinine. 
3 — Hydrotherapy in typhoid. 

SURGERY. 

1 — Gall stones, varieties, symptoms, treatment. 
2 — Hydrocele, varieties, treatment. 
3 — Spina Bifida, varieties, treatment. 

MEDICINE. 
1 — Mitral Stenosis, symptoms, diagnosis, treatment. 



210 

ST. JOHN'S HOSPITAL. 
Brooklyn. 

ANATOMY. 

1 — Give the arterial supply of the bladder. 
2 — Give the relations of the duodenum. 

3 — Give the structures divided in an amputation four inches 
below the knee joint. 

SURGERY. 

1--Give the symptoms of stone in the bladder. 

2 — Describe Pott's fracture. 

3 — Give the treatment of acute synovitis of the knee joint. 

GYNECOLOGY. 

1 — Give the different varieties of fibroid. 

2 — Give pathological conditions giving rise to menorrhagia. 

3 — Give treatment of 1 and 2. 

MATERIA MEDICA AND THERAPEUTICS. 

1 — What is Donovan's Sol.? Dose? When indicated? 

2 — Give relative strength of Pulv. Opii., Tr. Opii. and Codeine. 

Doses. . Indications for use and therapeutic effect. 
3 — Veratrum Viride. Official preparation. Dose. Indications 

for use. Effect. 

GENERAL MEDICINE. 

1 — Diphtheria. Complications. Treatment. 

2 — Bright's Disease. Varieties. Treatment. 

3 — Cerebro-spinal meningitis. Etiology. Symptoms. 

OBSTETRICS. 

1 — Stages of labor and dangers attending each. 
2 — Extra uterine pregnancy, description and management. 
3 — Indications of the use of forceps. Describe high forceps 
operation. 



LIST OF HOSPITAL EXAMINATIONS 

For 1904. 



BELLEVUE HOSPITAL (P. & S. Division) 

BROOKLYN HOSPITAL 

CHRIST HOSPITAL 

GERMAN HOSPITAL 

GERMAN HOSPITAL, Brooklyn. 

KINGS COUNTY HOSPITAL 

NEW YORK CITY HOSPITAL 

NORWEGIAN HOSPITAL 

NEWARK HOSPITAL 

POST GRADUATE HOSPITAL 

ROOSEVELT HOSPITAL 

ST. FRANCIS HOSPITAL 

ST. LUKE'S HOSPITAL 

ST. VINCENT'S HOSPITAL 

SENEY HOSPITAL, Brooklyn 

SMITH INFIRMARY. 



EXAMINATION PAPERS FOR 1904. 



BELLEVUE HOSPITAL (P. & S. Division) 

SURGERY. 

1 — Differentiate between, malignant and non-malignant tumors 

of breast. 
2 — Give varieties of club foot. Or else: 
3 — Give indications for ligation of ext. iliac. 

ANATOMY. 
1 — Describe rectum in following order: 

(a) Location and extent. 

(b) Curves. 

(c) Vessles. 

(d) Nerves. 

(e) Important surgical relations. 

2 — Describe circulation of mesentery, give one method of 
treating same after removing part of the gut. 

PATHOLOGY. 
1 — Give one test for: 

a, albumin in the urine. 

b, Sugar " " " 

c, Bile " " 
Give the ingredients used. 

2 — What are the pathological conditions for which tumor of the 
brain may be mistaken, and how would you differentiate 
each. 



BROOKLYN HOSPITAL. 
March 9, 1904. 

■Describe the symptoms and state the differential diagnosis 
of gall stone colic. 

Describe the symptoms of lobar pneunomia. 
State the action and uses of digitalis. 



214 

2 — List the causes of uterine hemorrhage and describe one 

variety in full. 
3 — Give the differential diagnosis of two surgical lesions in the 

lower half of the right side of the abdomen. 

What are the most common complications of strangulated 
hernia? 
4 — Give the motor and sensory nerve supply of the hand. 
5 — Give the symptoms of tubercular osteitis of the spine (Pott's 

disease.) 
6 — Give the mechanism of normal labor. 
7 — Describe the gross and miscroscopic changes in pulmonary 

tuberculosis from its incipiency to the early stage of cavity. 



CHRIST HOSPITAL. 

ANATOMY. 
1 — Describe a dorsal vertebra. 

2 — Name the triangles of the neck and give their boundaries. 
3 — Give the anatomy of the biliary duct. 

SURGERY. 

1 — Describe purposes and technique of intravenous saline in- 
fusion. 

2 — Give the pathology of appendicitis. 

3 — What is tendo-sinovitis and its treatment, why is it more 
dangerous in the thumb and little finger than elswhere in 
the hand. 

Oral Examination. 

ANATOMY. 
1 — Describe knee joint. 
2 — Describe seventh cranial nerve. 
3 — Describe female uterus and give relations. 

SURGERY. 

1 — Intestinal obstructions (acute) etiology, varieties, pathology 
symptoms, complications and treatment. 

2 — Differential diagnosis between backward dislocation of the 
head of the femur and fracture of the neck. 

3 — Osteomyelitis, etiology, symptoms, pathology and treat- 
ment. 



215 
GERMAN HOSPITAL. 

Oral Examination. 

Dr. Adler. 

MEDICINE. 

1 — Causes of vomiting. 

MATERIA MEDICA. 
1 — Derivatives, doses and preparations of Digitalis, Opium. 

PHYSIOLOGY. 
1 — Causes of heart contraction. 

PATHOLOGY. 

1 — Microscopic and macroscopic difference between Adenoma 
and Carcinoma. 

Dr. Kiliani. 

ANATOMY. 

1— Peritoneum, anterior abdominal wall and surgical anatomy 
down through pelvis and up rectum. 

2 — Surgical anatomy space of Retzius, pouch of Douglas, un- 
covered rectum, etc. 

3 — Man lifts weight, feels sudden sharp pain in abdomen. 
Symptoms of shock. What would you examine for? 

4 — What is hernia. Most frequent contents? 
Why most frequent in male adult ? 
Treatment and operations. 

5 — Bottini's Operation. What is it superseded by? (Exercis- 
ing of P.) 

6 — Man falls off house, lands on shoulder, most frequent lesion? 

7 — Chief complication of, directly induced f. of clavicle. 
(Brachial Palsy. Art. Vein and non-union.) 

GYNECOLOGY. 
1 — Have you ever seen a curettage? What is a curette? 
2 — What is purpose of curettage? 
3 — What are the causes of endometritis? 



216 

GERMAN HOSPITAL (Brooklyn). 
March 21st, 1904. 

Written Examination. 
ANATOMY. 

1 — Describe the course and distribution of the musculo-spiral 
nerve. 

2 — Describe the anatomical conditions which may render frac- 
ture of the femur near the thigh especially serious. 

SURGICAL ANATOMY. 

1 — Give the surgical anatomy of inguinal hernia. 
2 — Give the names of all structures which are severed in an 
amputation through the middle third of the thigh. 

SURGERY. 

1 — Give the differential diagnosis of the two most commonly 

observed tumors of the female breast. 
2 — Give the methods of examination, differential diagnosis, and 

treatment of an impacted fracture of the cervix femoris. 



KINGS COUNTY HOSPITAL. 

1 — Symptoms, diagnose treatment of tuberculous meningitis. 

2 — Indications and methods of inducing, premature labor. 

3 — Symptoms, physical signs and treatment of pulmonary 
edema. 

4 — What is the blood supply of the ureter? 

5 — Describe the peroneus longus muscle. 

6 — In what class of cases does intra-capsular fracture of the 
femur occur? For what may it be mistaken? 

7 — Give the differential diagnosis between a backward disloca- 
tion of the ulna and supra - condyloid fracture of the 
humerus. 

8 — Diagnosis and treatment of placenta preVia. 

9 — Describe portal circulation. 



217 

NEW YORK CITY HOSPITAL. 
April 5th, 1904. 

MEDICINE AND THERAPEUTICS. 

1 — <?, Name the infectious diseases of bacterial origin and the 
bacterium producing each. 

b, Name the exanthemata and the sequels which may 

result from each. 

c, Name those of doubtful bacteriology. 

d, Name those transmitted by the mosquito. 

2 — State the differential features in the temperature charts of 
Typhoid, (second week), Pneumonia, Septicemia, Miliary 
Tuberculosis, Pulmonary Tuberculosis (chronic). 

3 — Name two drugs which can usually be depended on to pro- 
duce sleep. 

What is the smallest dose of each which is likely to be ef- 
fective and the largest dose that may be safely given? 

4 — How would you treat acute gastritis from abuse of alcohol? 

5 — Write full orders for a nurse to carry out for one day's, 
treatment of a severe case of typhoid fever in the third 
week. 

SURGERY AND ANATOMY. 

1- — Fracture of skull. (Give treatment only of the following) : 

a, Simple, no depression. 

b, Simple, with depression. 

c, Compound, with no depression. 

d, Compound, with depression. 

2 — Mention six different causes of enlargement of lymphatic 
glands above the left clavicle, and give the proper treat- 
ment. 

3 — What anatomical structures in the finger determine the lo- 
cation of pus in acute abscess. Indicate briefly the appro- 
priate treatment in each case. 



OBSTETRICS AND GYNEGOLOGY. 

1 — a, Describe the second stage of normal labor with head in 
position L. O. A. 

b, How would you diagnose a face presentation from a. 

breech ? 

c, What preparations and arrangements are necessary- 

to secure an aseptic accouchment? 



218 

2 — a, What are the normal supports of the uterus? Which of 
these is the most important ? 

b, State etiology of Pelvic inflammation in woman. 

PRACTICAL. 

1 — T. B. Joint: Pneumonia with pleurisy. 

2 — Hepatic cirrhosis. — A full and very difficult examination at 
the laboratory, including Indican, Diacetic acid, and for- 
mula of urea, etc. 



NORWEGIAN HOSPITAL. 
March 30th, 1904. 

ANATOMY. 

1 — Give inervation and action of the Sterno- Mastoid Muscle. 
2 — Describe the course of the Lingual Artery. 
3 — Describe the Prostate Gland. 

4 — Give general course of the External and Internal Iliac ar- 
teries aud name their branches.. 

PATHOLOGY. 

1 — Give a list of the items to be noted in the examination of a 
twenty-four hour specimen of urine in hospital practice : 

a, Chemical. 

b, Microscopical. 

2 — Which items are the most important as an indication of 

renal insufficiency. 
3 — Describe briefly apparatus used for a white and red blood 

cell count. 
4 — What are the approximate number of red and white cells 

per cm. of normal human blood? 

SURGERY. 

1 — How would you treat a compound fracture of the leg. 

2 — Name the causes of pus in the urine. 

•3 — Give the varieties of Hernia. Describe one operation. 

GYNECOLOGY. 

1 — Name the tumors of the Fallopian tubes and give the dif- 
ferential diagnosis. 



219 

NEWARK HOSPITAL. 

SURGERY. 
1 — Symptoms and treatment of acute osteomyelitis. 
2 — Diagnosis and treatment of suppurative appendicitis. 



POST GRADUATE HOSPITAL. 

1 — Where would an embolus from the mesentery of the ap- 
pendix lodge? From a hemorrhoid? 

2 — What group of lymph glands would be likely to swell first 
from a focus of mixed infection at an incisor tooth? From 
t b c infection? 

3 — What bacteria live about the roots of the hair and escape 
ordinary disinfection? 

4 — Diagnose between gonoccus and acute rheumatic arthritis. 

5 — What structure is chiefly involved in a bunion? 

1 — Lobar pneumonia: — Definition, etiology, pathology, symp- 
toms, physical signs, prophylaxis, treatment. 

2 — Dose of tr. digitalis, strych. sulphat, acetanilid, morph. 
sulphate and toxicology of each drug. 

1 — a, What is the relative indication for the cesarean section? 
b, What is the absolute indication for the cesarean section? 

2 — Where does the ovum imbed under normal conditions? 

3 — Termination of neglected tubal pregnancy? 

4 — Physiological position of the uterus, the bladder and rectum 
empty? 

o — What form of cancer is most common in the body of the 
uterus? 



ROOSEVELT HOSPITAL. 

WRITTEN EXAMINATION. 
Dr. Weir. 

Surgical causes of bloody urine and how to distinguish 

source. 
Possible courses of extravasated urine in trauma or stenosis 
of deep urethra. 



220 

Dr. James. 

Describe best method of determining size of liver and con- 
ditions apt to lead to error. 
Differential diagnosis of Hemoptysis. 
Dr. Blake. 

Describe common bile duct. How would you distinguish 

it during an operation from portal vein? 
What position of appendix predispose to abscess formation 
and what positions to general peritonitis? 

Dr. Tuttle. 

Differentiate diagnosis appendicitis and acute pyosalp. 
Relations of ureters in female. 

ORAL EXAMINATION. 
Dr. James. 

Differential diagnosis between benign and. malignant ste- 
nosis of pylorus. 

Dr. Jackson. 

What drugs produce cutaneous eruptions? 
Dr. Blake. 

Line of incision for an excision of shoulder joint, anatomy 

of circumflex nerve. 
Differential diagnosis between benign and malignant 
tumor in breast of woman of 45. 

Dr. Weir. 

What is spermatocele? In what structure or structures 

does it arise? 
Indications for tracheotomy. 
Part of trachea selected for operation. 
How would one enlarge the incision in a high treachetomyr 



ST. LUKE'S HOSPITAL. 
ANATOMY. 

1 — Describe the pectoralis major. 
2 — Give the nerve supply of the muscles of the orbit. 
3 — State essential difference between direct and indirect in- 
guinal hernia. 



221 

SURGERY. 
1 — Aneurism, definition, varieties, surgical treatment of. 

MEDICINE. 

1 — Symptoms of cirrhosis of liver, due to disturbance of the 

portal circulation. 
2 — Symptoms and signs of malignant endocardicitis. 

Oral Examination. 

SURGERY. 

1 — Indications, temperature, strength of saline infusion. Colle's 

Fracture. 
2 — Differential appendicitis, gallstone colic, renal calculus. 

ANATOMY. 
1 — Two vertebrae to diagnose, kind and number. 
2 — Ligation of lingual artery. 

MEDICINE. 
1 — Complications and treatment of typhoid fever, third week. 

MATERIA MEDICA, 

1 — When administering digitalis, what symptoms of poisoning 
should you watch for referable to the heart and blood- 
vessels ? 
2 — What doses would you prescribe so be given three times a 
day of the following ? 

/, Tinctura nucis vomica. 
<?, Vinum Colchici Radicis. 
j, Extractum Digitalis Fluidum. 
^, Liquor Potassi Arsenitis. 

5, Sodii Phosphas. 

6, Acidium Hydrocyanicum Dilutum. 

7, Extractum Belladonnae Radicis. 

8, Potassi Acetas. 



222 

ST. VINCENT'S HOSPITAL. 

MEDICINE. 

1 — Dysentery, varieties, etiology, pathology, complications, 
diagnosis and treatment. 

GYNECOLOGY. 

1 — Describe varieties of fibromata uteri, give symptoms of each 
variety. 

SURGERY. 

1 — Differential diagnosis between, subphrenic and hepatic 

abscess and empyema. 
2 — Between empyema of gall bladder and appendicitis. 

ANATOMY. 

1 — Describe ligation of the internal iliac artery. 
2 — Answer one of the following : 

a, Give relations of vessles in the pelvis of kidney. 

d, Locate and describe the prostate gland. 

c, " " " " seminal vesicles. 

Dr. Aspell. 

Treatment of Uterine hemorrhage, third stage. 
Causes of uterine hemorrhage. 
Third stage of labor. 

Dr. Stewart. 

Suppression of urine. 

Retention of urine, ) Can fa be confused? 

Incontinence of urine, j J 

Give example. 

Resection of knee, lines of incision. 

Best method. 

What is arthrectomy? 

What is excision of a joint? 

Discuss leucocytosis in various forms of appendicitis. 

Dr. Bissell. 

Coverings of the testicle. 

Hydrocele define 

Treatment. 

Cystitis, treatment. 

(He wants perineal section and drainage if any operative 

methods are used) 
Diagnosis of sarcoma of testicle. 



223: 

Dr. Ferrer. 

Complications of typhoid fever. 
Most frequent sequelae. 
Treatment of internal hemorrhage. 

Dr. Mandel. 

Slides of malaria, leukemia, urine crystals, filaria, starch, 

granules. 
Value of Diazo, its occurrence and when. 
Value of indican, drugs causing reactions similar to it. 



METHODIST EPISCOPAL HOSPITAL (SENEY) 

Brooklyn, N. Y. 

ANATOMY. 

1 — How would you apply a trephine to expose : 

a, The mastoid antrum. 

b, The lateral sinus. 

2 — Give sensory nerve supply of the upper extremity. 

GENERAL SURGERY. 

1 — Give the differential diagnosis between the different forms 

of intestinal obstruction. 
2 — Give the indications and contraindications for amputation in 

gangrene. 
3 — State the complications and sequelae of penetrating gunshot 

injuries of the chest. 

GENITO-URINARY SURGERY. 

1 — Enumerate the causes of hematuria. 

2 — Give the symptoms of trans- peritoneal ruptures of the urin- 
ary bladder. 

3 — Describe the symptoms and complications of floating 
kidney 

GENERAL MEDICINE. 

1 — Describe the symptoms of and cause of acute anterior Poly- 
myelitis. 

2 — State varieties, symptoms and differential diagnosis of ar- 
thritis deformans. 



224 

OBSTETRICS. 

1 — Give the diagnosis and management of placenta previa. 
2 — State the differential diagnosis of ectopic gestation. 

THERAPEUTICS. 

1 — Give the therapeutic action of: 

a, Amyl nitrite. 

b, Thyroid extract. 

PHYSIOLOGY. 

1 — How do proteids differ from peptones? 

2 — Describe the more important functions of the spinal cord. 

PATHOLOGY. 

1 — Give the differential diagnosis as based on an examination 
of the blood, between typhoid fever and malignant endo- 
carditis, and describe the post-mortem findings in both 
diseases. 



SMITH INFIRMARY. 

SURGERY. 

1 — Describe the various steps in Pirogoff's amputation. 
2 — What is the most frequent site of fracture of the clavicle 
and describe a method of treatment. 

ANATOMY. 

1 — Describe the Brachial artery. 
2 — Describe the head of the femur. 

MEDICINE. 

1 — Of what are gall-stones composed? 

2 — When and where are they formed? 

3 — To what symptoms do they give rise? 

4 — Give medical treatment, prophylactic and otherwise. 



225 
MATERIA MEDICA. 

1 — Give the physiological action, the therapeutic use and ad- 
ministration of: 

a, Veratrum Viridi and dosage ; 

b, Adrenalin. 

OBSTETRICS AND GYNECOLOGY. 

1 — Give the diagnosis and management of an R. O. P. 
2 — Differentiate between acute, salpingitis and a ruptured 
ectopic. 

CLINICAL PATHOLOGY. 

1 — Describe three tests for albumin in the urine. 
2 — Describe method of staining for tubercle bacilli in sputum. 
Give ingredients of all reagents used. 

Oral Examination. 

SURGERY. 

1 — Varieties of dislocation of head of humerus. 
2 — In what position would you put up a fracture of the head of 
the radius. 

ANATOMY. 

1 — Give the branches of the external carotid. 
2 — Describe the lumbar plexus. 

MATERIA MEDICA. 

1 — Give dose of tincture and fluid extract and digitalis. Give 

its therapeutic use and contra indication. 
2 — Symptoms and treatment of opium poisoning. 

MEDICINE. 
1 — Give treatment of uremia. 
2 — Give treatment of appendicitis and when would you call in 

surgeon. 
3 — Give symptoms of perforation in typhoid. 

OBSTETRICS. 
1 — Give treatment of P. P. hemorrhage. 



226 

Practical Examination. 

MEDICAL WARD. 

1 — Case of chronic lead poisoning to diagnose and give treat- 
ment. (Case showed lead line on gums and had wrist 
drop — no colic.) 

SURGICAL WARD. 

1 — Colle's fracture to diagnose and put on dressing. Fracture 
had been reduced and was about two weeks old. 

LABORATORY. 

1 — Two urines to examine: Tubercle bacilli. 
2 — Two slides to diagnose : Pneumococci. 



ST. FRANCIS HOSPITAL. 

Written Examination. 

1 — a, Describe the mastoid antrum. 

&, What structures may be injured in operating in this 
region? 

2 — Describe the action of the heart in diastole and systole. 

3 — Mention some of the pathological processes leading to en- 
largement of the liver. 

4 — Give the chief symptoms of lobar pneumonia as differing 
from serous pleurisy. 

5 — Give the chief symptoms of typhoid fever as differing from 
those of malarial fever. 

6 — Give the symptoms and the treatment of fractures of the 
neck of the femur. 

7 — What are the causes of intestinal obstruction (acute and 
chronic) ? 



227 

8 — a y What are the effects of Belladona on the circulation, 
respiration, intestinal tract and eye? 

b, Mention other drugs acting in a similar manner on these 
functions. 

9 — a, State the official preparations of digitalis and dose of each. 

b, Discuss briefly the effect of this drug upon the circula- 

tion and kidney. 

c, What symptoms or physical signs would indicate its use 

in heart disease? 



Dr. Downing. 

1 — Causes of convulsions? 

2 — Causes of vomiting. 

3— Causes of dyspnea. 

4 — Changes in blood in anemias and leukemias. 

5 — Symptoms of cerebro-spinal meningitis. 



Dr. Lloyd. 

1— Structures to be avoided in doing a pan-hysterectomy and 
and their relations to the uterus. 

2 — Relations of deep epigastric artery to external and internal 
abdominal rings. 

3 — Relation of axillary artery. 

4 — Femoral ring, describe. 



Dr. Kammerer. 

1 — Causes of stricture of rectum. 
2 — Causes of swelling of lymph glands of neck. 
3 — Tumor of the breast, varieties. 

4 — Pathology of intestinal obstruction (gangrenous and non- 
gangrenous). 

Dr. Seibert. 

1 — Given temperature of 104-106* F. What may it be. Ans. 
Pneumonia, follicular tonsilitis or malaria. Every year 
every man gets this question. 



228 

Dr. Switzer. 

1 — Digestion of meat, proteid and fat. 

2 — What food contains largest amount of glycogen? 

3 — In what disease is the glycogen storing functions of the 
liver disturbed? 

4 — Where is the glycogen then found? 

5 — Tests for same. 

6 — What drugs reduce Fehling's solution? 

7 — Causes of intestinal hemorrhage. 



Dr. Warren. 
1 — Antidotes for arsenic, phosphorus and mercury. 

2 — Effects of strychnine. Causes of death from strychnine 
poisoning. 

3 — Hives Syrup. 

4 — Tartar Emetic. 

5 — Preparations of Iron. 

6 — Preparations of mercury. 



INDEX. 



Abbe's fish line treatment, 115 

Abbe, on radium, 124 

Adenoma, 122 

Ampulla of Vater, 152 

Andrew's technic, 184 

Aneurisms, differential, 31, 32 

Aneurisms, 27 

'' pathology of, 29 

Angiotribe, 42 

Animal parasites, 188 

Appendicitis, 135 

differential, 137, 138 
invagination of, 140 
recurrent, diff., 155 

B 

Banti's disease, 150 
Bilharzia hematobia, 194 
Bevan, on cryosopy, 157 
Bladder, 160 
Bladder stones, 161 
Blake, on diverticulae, 186 

' ' treatment of patellar fracture, 78 

" value of X-ray, 171 
Bland-Sutton, 180 
Bloody urine, 160, 161, 162 
Bone pressure, spinal differential, 112 
Bottini's operation, 164 
Brain hemorrhage, 102 
Breast, malignant diseases of, 120 
Brewer, classification of stones, 162 

44 on hernia, 183 

" on gall ducts, 147 

" method closing arterial 

wounds, 38 
reference to sepsis, 65 
Brophy's technic, 185, 186 



Bryant's triangle, 172 
Burn contracture, differential, 51 
Bursae, differential, 32 
" 53 



Calcium chloride, 37 

Capillary formation, 22 

Carcinoma, 122, 181, 187 
44 of liver, 152 

" pyloris, diff . 129, 130, 131 
44 rectum, diff., 142 

Celiac axis, 125 

Cerebral abscess, 107 

44 diff., 108, 109, 110, 111 
44 tumor, diff., 108, 109, 110, 111 

Cestodes, 188 

Chancroids, differential, 86, 87 

Chemotaxis, 20, 25 

Child, on Bursae, 53 

Cholangitis, 152, 138; diff., 129 

Cholecystitis, diff., 129, 130, 131 

Chyluria 58, 192 

Cleft palate, 185 

Cloudy swelling, 18, 24 

Colle's fracture, 173 

Colon, 140 

D 

Dawbarn, appendix technic 128 

44 scheme for aneurism liga- 
tion, 35 
44 on starvation, 124 

Decortication vs capsule section, 159 

Degeneration of benign growths, 121 

Diapedesis, 17 

Dislocations, 178 

Diverticulae, 115 



230 



INDEX. 



Dunham, method of passing stricture, 

115 
Duodenal relations, 127 

ulcer, 128 
Dupuytren's contracture, 49 

diff., 51 
Dry productive inflammation, 24 



Echinococcus, 189 

Ectopic, right ruptured, diff., 137, 138 
Emerson, on decortication, 159 
Empyema 117; differential, 148 
Epiphysitis, 73; differential, 81 
Epithelioma, differential, 86, 87, 88 
Esophagus, 115 

diverticulae, 115, 116 
Extrophy, 186 



Fasciae, 48 

Ferguson, A. H., on decortication, 159 

Filariae, 192 

Fractures, 166 

of clavicle, 173, 174 
" of patella, 178 

of skull, 174 



H 

Harris' segregator, 157 
Hematuria, 160 
Hemorrhoids, differential, 142 
Hernia, 182 

internal, 183 
Herpes, differential, 86, 87 
Hydatid disease, 190 
Hydrophobia, diff., 67, 68, 69. 
Hypodermoclysis, 63 
Hysterical spine, diff., 78, 79, 80 



I 



Imbrication methods, 184 
Inflammation, 16—26 
Infusion, 63 

Intestinal obstruction, 142, 143, 144, 145 
Invagination of appendix, 140 
Ischio-rectal fossa, 92; abscess, diff., 
94, 95 



K 

Kidney, 153 

" nephropexy, 155 

" prolapsed, differential, 155 



Gastro-duodenal ulceration, chronic, 
differential, 152 

Gastro-enterostomy, 133 

Gastritis, differential, 155, 156 

Gastrostomy, 134 

Gall bladder, 147 

Gall-stones of common duct, differ- 
ential, 129, 130, 131 

Genito-urinary, 153 

Glands, 55 

Goodfellow, on prostate, 164 

Gonorrheal arthritis, diff., 89, 90, 91 

Grand-mal, differential, 99, 100 

Granular change, 18 

Gravitation diseases, 40 

Gumma, differential, 31, 32, 33 



Labial chancre, differential, 86, 87 

Laminectomy, 113 . 

Leucocytosis, diseases characterized 

by absence 139 
Linea aspera, 167 
Liver, 147 

abscess, differential, 148 
" carcinoma, differential, 152 
Loose body in joint, diff., 89, 90 
Lumbar plexus, 45 
Lupus, 106 
Lymphactic ducts, 57, 58 

" 'of female genitals, 59 
Lymphactic glands, 55 
Lymphactic vessels, 55 
Lyssophobia, differential, 67, 68, 69 



INDEX. 



231 



M 

Madyl's operation, 161 

Malformations, 185 

Malignancy, 71, 142 

Matas' artificial respiration, 115 
massive infiltration, 164 
operation for aneurism, 37 

Mayo, on hernia, 184 

McCosh, on sarcoma, 182 

Median nerve section, diff., 51 

Meningitis, diff., 108, 109 

Muscles, 47 

" contractures, 48 

N 

Nelaton's line, 173 
Nematodes, 188 
Nephrolithiasis, diff., 155, 156 
Nephropexy, 155 
Nerves, 45 
Nevi, 43 

capillary, 43 

" cavernous, 43 

' ' Wyeth's hot water, 44 

O 

Ochsner's treatment for appendicitis, 

139 
Occupation diseases, 53 
Opie on pancreas, 152 
Osteomyelitis differential, 81 
Otitis media, 106, 107 



Pancreas, relations of, 150 

Pancreatitis, chronic, 152 

Papal benediction, 49 

Paracentesis, 117 

Perineum, local anesthesia of, 165 

Perineal prostatectomy, 164 

Phagocyte, 25 

Phebitis, 38, 39 

Pleura, limits of, 114 

Popliteal space, 28, 29, 30 

Pott's disease, differential, 78, 79, 80 

Productive inflammation, 19 — 25 



Pre-patellar bursitis, 53 

Prolapsed kidney, differential, 155, 156 

Prostate, 163 

Prostatitis, differential, 94, 95 

Prostatectomy, 164 

Pus, 23, 24, 25 

Pyloric stenosis, 133 



Radium, 124 
Rectum, 186 
Renal decortication, 159 

" relations, 154 

'' sepsis, 158 
Rheumatic arthritis, diff., 89 
Rheumatism, diff., 74 — 78 

of ankle joint, diff., 76 
Round cell zone, 20, 21 



Salpingitis, right sided, diff., 137, 138 

Sarcoma, spinal, diff., 112 

Scar, 19 

Scoliosis, differential, 78, 79, 80 

Schede's moist blood clot, 29 

" operation, 40 
Septic arthritis, differential, 81, 82 
Shock, 61 

Space of Retzius, diff., 94, 95 
Spinal sprain, diff., 78, 79, 80 
Spleen, 149 
Spondylitis, 78, 79, 80 
Starvation, 124 
Static spray, 24 
Stomach, 132 

" pyloric stenosis, 133 

Sub-phrenic abscess, diff., 148 
Syphilis, 83 

of ankle joint, diff., 76, 77 
labial chancre, diff., 86, 87 
Syphilitic coxitis, diff., 74, 75 



Temperature table, 66 
Tendons, 51 

transplantation, 53 



INDEX. 



Tenosynovitis, 52 

Terminations, 56, 57 

Testicular differentials, 162 

Tetanus, differential, 68, 69 

Tetany, 69 

Tinker, 42 

Tinker, on prostates, 164 

Toxicity, raised by pressure, 136 

Transverse myelitis, diff., 112 

Trematodes, 188—191 

Trephine areas, 103 

indications, 176 

Tuberculosis, 69 

ankle joint, diff., 76, 77 
arthritis, diff., 89, 90, 91 
coxitis, diff., 74, 75 
" meningitis, differential, 

108, 109, 110, 111 

Tuffnell's treatment, 36 

Typhoid, differential, 108, 109, 110, 111 
" surgery of ulcers, 135 

U 

Ulcer-bearing pyloric funnel. 128 
Ulcer of pyloric funnel, differential, 
129, 130, 131 



Ulnar, nerve section, differential, 51 
Ureteral catheterization, 157 
Uretero-ureterostomy, 160 
-vesical valves, 161 
Urinary segregation, 157 

V 

Varicocele, 41 
Varicose veins, 40 

W 

"Walled off", 18, 19, 25, 71, 107, 140 
Wefr, marsupialization, 141 
Wens, 187 

Wet productive inflammation, 24, 25 
Wyeth's treatment of Nevi, 44 



X 



X-Ray, 123, 157, 166 



Young, on prostates, 164 



SEP 29 1904 



